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THE SHAPING OF PSYCHIATRY BY WAR 



THE SHAPING 

OF PSYCHIATRY 

BY WAR 



By JOHN RAWLINGS REES, M.D. 

BRIGADIER: CONSULTING PSYCHIATRIST TO THE BRITISH ARMY 

MEDICAL DIRECTOR, THE TAVISTOCK CLINIC, LONDON 



CHAPMAN AND HALL, LTD. 

37-39 ESSEX STREET STRAND 

LONDON, W.C. 2 



First published in C^reat Britain 1945 



PRINTED IN THE U.S.A. 



COMMEMORATING A GREAT PREDECESSOR 
THIS BOOK IS DEDICATED TO ALL 

ARMY PSYCHIATRISTS 



"The last few years have seen a rapid extension of the frontiers of all 
branches of medicine, especially in their social applications. Dealing, as 
it does, with the deep springs of human conduct, k is not surprising that 
psychiatry should have extended its own frontiers in this direction even 
further than have some other branches of medicine." 

DR. THOMAS W. SALMON, in The Military Surgeon, XL VII, 200, 1920 



CONTENTS 

FOREWORD 9 

CHAPTER I THE FRONTIERS EXTEND 13 

CHAPTER II OPPORTUNITIES EMERGE 52 

CHAPTER III THE WAY AHEAD 117 

APPENDIX THE TASKS OF PSYCHIATRY 140 

INDEX 155 



FOREWORD 



There can hardly be a greater compliment paid to a British 
psychiatrist than that he should be invited to the United States to 
deliver these lectures which commemorate that very great man 
Doctor Thomas W. Salmon. As you may imagine, I am extremely 
sensible of that honour. 

I have always counted myself most fortunate to have met Doctor 
Salmon on my first visit to this country. Whilst acquiring the habit 
from some of you of speaking of him as Tom Salmon, I unfortu- 
nately never knew him well enough to be on those intimate terms 
with him. After his death, along with many other modest con- 
tributors to the Memorial Fund, I little dreamed that one day there 
might be the opportunity of paying some public tribute to the man 
who had impressed me so much. At that time few of us had any 
prevision of another war, and though it was common knowledge 
that he had played a big part in shaping and directing the psychi- 
atry of the United States army during the 1914-18 war, I had no 
conception how great that contribution was. Volume ten of your 
United States Army Medical History had not been published then, 
or it had certainly not come to England, but in the year that pre- 
ceded this present war and during the early years of hostilities, that 
volume, and in particular Colonel Salmon's contributions to it, 
were a "Bible'* for military psychiatry in Britain. 

Perhaps it is appropriate that in World War II a psychiatrist 
from Great Britain, who has been concerned with exactly the same 
problems that Colonel Salmon faced in the other war, and who has 
learnt so much from his work, should have this opportunity of say- 
ing so and of trying to show where still further progress can be 
made. 

You in the United States have thrown up so many of the leaders 
in the modern development of our specialty that we in Great 



io FOREWORD 

Britain, as indeed psychiatrists the world over, are heavily in your 
debt. While we have lagged behind in some ways we have not 
done too badly in others. Our allied experiences will take us for- 
ward with you in the postwar world. 

Wars have, I suppose, always been wasteful and destructive, yet 
at the same time, out of the peculiar conditions created by conflict 
and national effort, there seem to have come some things that are 
of value. There is no time and no experience in our whole social life 
in which psychological principles are so challenged as in war, and 
psychiatry has perhaps matured more as a result of war experience 
than it could have done in five years of peace. This book and the 
lectures on which it is based are an attempt to catch some of the 
lights and shadows of wartime development, and I hope that they 
will stimulate thought as to how we can best capitalize the tragic 
experiences of society at war. 

You will, I am afraid, not find in these pages any apposite his- 
torical references. I am not a historian, and if those things were 
here they would all have come out of someone else's book. I suspect 
that anyhow most of you know more of the background of psychi- 
atry than I do. Hence in these pages there are merely the reflections 
of a physician who has been and still is faced with a very practical 
job, concerned with the efficiency, mental health and stability of a 
large and complicated group of his fellows. There is very little 
that is original in this book; plagiarism has during this war become 
second nature to me, and not only the ideas but much of the phrase- 
ology which I now regard as my own derive, in fact, from my col- 
leagues in psychiatry, psychology and medicine. 

These lectures are not an attempt to give a full description of such 
methods and techniques as have been devised during the war. Most 
of the procedures that I shall refer to deserve carefully written and 
well-documented descriptions of a technical kind, for which there 
is no space here. I propose only to use them as part of the detail 
of a picture on a fairly large canvas. 

I have referred to my colleagues in the army from whom I have 



FOREWORD u 

learnt so much. Whether in the War Office, commands at home, 
or in Africa, India, Italy or France, their work is never-ending. 
Theirs is the stimulus which has made these lectures possible for 
me. This is, therefore, the beginning of those acknowledgments 
which form part of any preface or foreword. My thanks are certainly 
no formal matter. Lieutenant General Sir Alexander Hood, the 
Director General of the British army medical services, has done much 
more than send me across the Atlantic again with permission to 
give these lectures. He has given enlightened direction, encourage- 
ment and his very active backing to our work at all times. The 
Adjutant General of the British army, General Sir Ronald Adam, 
has played a very special role which needs public acknowledgment. 
His vision and courage led to the development, not only of selection 
procedures of various kinds in the army, but also of a great number 
of other sociological experiments, some of which I shall refer to in 
these pages, and his deliberate contribution to social medicine and 
social psychiatry as well as to winning the war is difficult to over- 
value. The third person whom I wish to mention by name is my 
colleague Brigadier Hugh Sandiford, whom in 1942 we lured from 
the respectable realms of army hygiene to be the first Director of 
Army Psychiatry, and whose wisdom and administrative farsighted- 
ness in the development of our work have been most significant. To 
all of these, and to others unmentioned, I owe a great debt of 
gratitude. 

Practically one third of my thirty years as a physician has been 
spent in uniform. Especially during the five years of the present 
war I have realized the immensely valuable experience which service 
life and facilities can provide for the doctor and the sociologist. 
When ideas and realistic suggestions receive backing, the possibilities 
for group exploration and experiment are almost unbounded. If 
psychiatry did not make some interesting contributions as the result 
of its opportunities in wartime, there would be something funda- 
mentally wrong with psychiatrists. 

J. R. REES 



CHAPTER ONE 

THE FRONTIERS EXTEND 



THERE must always be some definite end in view to justify the prepa- 
ration of lectures or the writing of a book. Often there are facts to 
be recorded and always there are certain ideas which are seeking for 
expression, and often some convictions which the author hopes to 
implant in the mind of the reader. The speaker or writer has often 
been compared with the lawyer, one of whose main tasks is to con- 
vince his jury and to get from them the verdict that he seeks. That 
is actually a very useful parallel and imposes on one the necessity to 
decide beforehand what verdict one is hoping for from the jury, i.e. 
the audience or the readers of the book. It will perhaps be as well, 
therefore, to say at the beginning rather than at the end what verdict 
is sought through the writing of these pages, and it can perhaps be 
expressed like this. 

The experiences of war are by no means altogether sterile. 
Some, and perhaps many, of the responses made in wartime to 
challenging situations are of interest and of a value which has 
some permanence: the experience can be utilized and developed 
for the good of the community in peace. Psychiatry has a more 
important role to play than it has ever had before since there is 
an increasing awareness of what it can contribute, and conse- 
quently there will be an ever-increasing demand for competent 
psychiatric advice and help. On all psychiatrists, therefore, there 
is a big responsibility, not only to try to undertake the tasks that 
are given us but also to see that the standards of psychiatry and 
of psychiatrists are constantly improved. This is a personal re- 
sponsibility for each of us. 

Having stated in these somewhat vague terms the thesis of these 
lectures, one must try to fill in the details as fully as possible. It 



I 4 THE SHAPING OF PSYCHIATRY BY WAR 

would, of course, be quite presumptuous to claim or imply that this 
is more than a partial picture of the changing situation in psychiatry. 
Of necessity the survey is limited because for one thing five years of 
absorption in the British army and its affairs has meant a very limited 
acquaintance with other things that were happening outside. Of 
much that has been taking place in civilian medicine and psychiatry 
in my own country I am ignorant. Much has happened in the univer- 
sities and research laboratories of Great Britain and a great deal more 
has been undertaken and carried through in the United States, Canada 
and elsewhere. The knowledge that these developments are going 
forward does not, unfortunately, make it possible to digest their find- 
ings and incorporate them at this stage into one's own presentation. 
That must therefore be accepted as partial and incomplete. 

An interesting phenomenon has made itself evident during this 
war. Perhaps it results partly from the stimulus of war and partly 
from the isolation of the times, but again and again one has discovered 
that the trend of ideas and the development of new points of view 
in one country have been paralleled almost exactly by similar develop- 
ments in other countries. This has been especially true in my personal 
experience as between psychiatric thought in Canada and the United 
States and in Britain during this war. Possibly it comes from the fact 
that armies, by the nature of their organization and the similarity of 
their problems, must stimulate the development of solutions that have 
much in common. It seems that the issues are by no means limited to 
matters military but widen out on to social and group situations of all 
types and in many fields. The fact that this is so certainly leads one 
to the belief that there must be something true and valuable about the 
solutions that have emerged quite independently in different conti- 
nents. What is true of army experience must certainly be true of the 
other fighting services and is probably indicative of the movement 
that is taking place in civilian groups everywhere. 



THE FRONTIERS EXTEND 15 

THE ARMY AND THE PEOPLE 

War has always created situations of difficulty for individuals, and 
the summoning together, the training and the utilization of armies 
have always created group problems of a psychological nature, gen- 
erally recognized as such though the actual terminology may be new. 
In classical history, in that of biblical times, and all through the 
earlier wars up to our own day and the so-called Great War, his- 
torians have given us factual material in plenty from which we can 
draw conclusions of psychiatric interest. War pulls men up by the 
roots and demands new adjustments from people of all kinds and 
types. Some of these are adaptable and well balanced and we hear 
little of them; others have a rather tenuous hold on life and their 
environment, others have never made a satisfactory adjustment to 
their own peacetime existence so that they can hardly be expected to 
make an easy or satisfactory adaptation to a new group life. 

War does something more than this in that it forces men and women 
to face many new challenges to instinct: aggression, which has had to 
be controlled, must now be brought out, trained and used against the 
enemy; men must learn to kill as well as to face the prospect of being 
killed. Taking life involves the breaking of taboo, which is no light 
matter and is liable to leave behind it guilt and depression. Savages 
had expiatory rituals after battle but modern man, of necessity, has 
to find a philosophy to meet the situation. He must learn early to face 
and not to ignore the necessity for killing his enemy, for unless he 
does he may break in training and he may have a postwar aftermath. 
Uprooted, and faced by primitive necessities which are especially 
alarming to many, the soldier must then go further and learn to re- 
shape his existence in other ways. The independence and self-reliance 
that he has developed during childhood and adolescence have now to 
be given up (or so he thinks) for the implicit obedience of the disci- 
plined soldier. He feels that he has to become a child again, dependent 
and as docile as can be. In fact this is what does happen although in 
every army we have outgrown much of this and can utilize to the full 



16 THE SHAPING OF PSYCHIATRY BY WAR 

the independence and self-reliance of the individual within the group. 
Nevertheless, many difficult adjustments are needed and not every 
basic training unit is able to provide ideal help in these adaptations. 
The present war is called total war, and that has meant that the 
civilian population is more involved in the army's life and the army's 
difficulties and dangers than has ever happened previously. Appro- 
priately, as I write this my room shakes, for a ton of explosives in one 
of our "flying bombs" has gone of! nearby. We cannot forget that 
the civilian population is in the war. Just as the civilian has had many 
similar adjustments to make, so the soldier finds his anxieties in- 
creased by the very fact that his family at home has to suffer these 
difficulties and stresses this apart from and in addition to his own 
inner separation anxiety. The army certainly provides problems 
which would be difficult enough to solve even were its human ma- 
terial of perfect quality. 

The British army has necessarily contained a proportion of men 
and women in the women's service who could never be said to be of 
perfect quality or anywhere near that. The manpower problem is 
very real and has through most of the war been very difficult. Con- 
sequently the army has had to take into its service many who were 
not fully adequate, either physically or mentally, and has dealt with 
rather more of this group proportionately than its sister services the 
Royal Navy and the Royal Air Force. For this reason the psychiatric 
experience of the British army, upon which these lectures are largely 
based, has come from the management of many difficult problems. 
Psychiatry has had more to do just because of the poor quality of some 
of the men and women taken into the army. 

This war has been different from other wars, a fact which has 
brought out psychiatric factors of some importance. The enthusiasm 
and sense of easy conviction, for example, have been less marked in 
this war than they were in the last war. Twenty years of industrial 
and social difficulty, of international crises, and disillusionment no 
doubt provide the major explanation for this. Ideologies are not easy 
things to explain, and yet this war has had to be fought on a much 



THE FRONTIERS EXTEND i; 

more rational, unemotional basis, and that greatest of all psychological 
problems, die morale of an army, has consequently been very much 
in our minds. New techniques have had to be devised for educating 
and orientating men and women to the war and to this changed atti- 
tude to war as a phenomenon. It would seem as though the German 
attitude to war had changed very little but in the democratic coun- 
tries the reverse is true. Where men are actually in the battle these 
issues do not arise so much as when they are waiting and training 
and waiting, and there has been a good deal of that in this war. For- 
tunately the concepts of a police war and of killing as an almost 
"surgical" necessity have been accepted very much more widely than 
in earlier days. Though no answers can be provided at the present 
time for many of the questions and difficulties which confront us in 
this changing social structure, it is certainly true that psychiatry has 
on the whole proved to have a partial answer to some of the prob- 
lems. Probably we have a more effective set of concepts than most 
groups of men, and it is for that reason that psychiatry has been able 
to make some contribution to the solving of many of these situations 
and has been able to offer new points of view to many people. 

THE DOCTOR AND HIS PART IN THE WAR 

In our army some 6 per cent of the medical men are regular soldiers 
or permanent force, and all the rest came straight in from civilian 
life. Like other men in the country, some came willingly and in- 
telligently, some grudgingly and some reluctantly. Since the medical 
officer in the army has at least as much to do with the morale and 
efficiency of the men as anyone else, any kind of unwillingness handi- 
caps him from the start. Fortunately, however, there has been little 
of this. Most doctors are individualists and proud of it, so that it is 
not an easy adjustment for a medical man, who comes in with a 
direct commission as an officer, to fit into the complicated arm) 
machinery. The doctor, also, is a humanitarian in his interests and 
he finds it somewhat difficult to adapt himself to his new task ol 



i8 THE SHAPING OF PSYCHIATRY BY WAR 

maintaining efficiency, keeping the maximum number of fit men on 
duty, and there is at times a tendency on his part to go too far the 
other way and to become a martinet, and, possibly a malingerer 
hunter. 

Those of you who have read Montague's Disenchantment, written 
after the last war, will remember his description of the medical board 
which sent you back to duty if you said you had any symptoms and 
which if you said you were quite fit put you on prolonged duty at the 
base. The doctor in the army has in many cases got to learn afresh to 
know and value human personality, and there is no place where he has 
better opportunity of coming to know and to understand and to 
respect his fellow man. The "interesting cases" and rare diseases with 
which we are so concerned in civil life are, in fact, so very unimpor- 
tant in the larger purpose of the army that the world would hardly be 
altered in its course today if all the people with interesting and rare 
diseases died; but the less romantic and exciting conditions, as for 
example, flat foot, venereal disease, hernia, neurosis and bronchitis, 
matter tremendously, and to deal with these efficiently is to make a 
major contribution towards winning the war. 

The doctor has certainly to concern himself both with health and 
with prophylaxis. It can almost be said that the main function of the 
medical services in battle is to sustain morale. Men fight better with 
an efficient medical service behind them safeguarding them from 
mutilation or death, and whilst not all of the wounded may get back 
to active service the fact that the medical services are there plays a 
very important part. The doctor is not really a noncombatant. True, 
he does not fire weapons at the enemy, but unless he regards himself 
as having an essential part to play in preparing and sustaining the 
men who fight and a vital interest in their task that in fact he is a 
combatant in spirit he will not find himself very happy in his job 
nor be very effective. 

This combatant spirit that is necessary comes from a deep sense of 
conviction about the values for which we fight and it leads the doctor 
to an attitude towards the enemy which might be described as that of 



THE FRONTIERS EXTEND 19 

a "social surgeon." Hatred and other sentimentality play no useful 
part in this. They may indeed be very harmful. 

The medical officer in the army has to think in terms of groups 
and group welfare rather than of the individual patient. He has also 
to decide to some extent which of the particular medical problems 
that confront him are to have priority. Possibly both of these are atti- 
tudes which should find their counterpart in civil medical practice 
also. The good medical officer makes himself an essential part of 
whatever unit he is with. He works and plays with the men when 
opportunity offers. He has an essential welfare function, indeed some- 
times he may be regarded as the mother of the unit with the com- 
manding officer as the father. His essential medical role, his readiness 
to listen, his sympathetic understanding coupled with kindly firm- 
ness give him an enviable position in which he is trusted and re- 
spected by nearly everyone, and in that role he can influence the well- 
being of the whole group. Welfare is inseparable from medicine and 
in any planning for health services for the future it must be recog- 
nized that welfare procedures, as an extension of medical social serv- 
ices, must play a part. The psychiatrist shares this life with all other 
army doctors and equally it is clear every doctor in an army needs a 
psychiatric viewpoint. 

The task of the doctor in the army, with its influence over individ- 
ual officers and men, his special position of confidence and leadership, 
points the way to the position that medicine as a whole should occupy 
in the management of larger groups, in the planning not only of 
methods for maintaining health but also of the larger sociological 
issues that concern groups, communities and nations. 

THE PSYCHIATRIST IN THE ARMY 

In World War I the British army had a "consulting psychologist" 
and a number of neurologists. Many of them, in fact, were psychia- 
trists. They were brought into the army's machinery in response to 
the critical situation created by the wave of battle neurosis at first 



20 THE SHAPING OF PSYCHIATRY BY WAR 

called "shell shock." As you know, Doctor Thomas Salmon came 
over to England in 1917 and was largely instrumental in forming the 
wise and statesmanlike plans that eventually came into being for the 
United States army. These included a much more liberal establish- 
ment of psychiatrists, or neuropsychiatrists as you called them even 
then. The main concern of psychiatrists in the last war was with 
treatment and they were very successful in treating battle neurosis 
just behind the lines and in tackling the more resistant cases in base 
hospitals. Those men who had to be evacuated out of the theatre of 
war to hospitals at home proved more of a problem. 

This was probably the first time psychiatrists had ever been used 
deliberately in war and their work, which is detailed in many volumes 
apart from the formal medical histories of the war, produced a very 
great effect upon the development of psychiatry as well as making a 
considerable contribution at the time to the successful prosecution of 
the war. More will be said about this later on, and at this moment it 
seems profitable to look at our most recent experience and learn 
something about the type of psychiatrist and the type of training that 
seem most valuable. 

War experience is a valuable testing ground for most of us and 
certainly this is true for psychiatrists. Under army conditions one 
perhaps discovers more easily and more rapidly than under any other 
situational stress what the personality and quality of a man are. For 
many, war has meant leaving the almost cloistered seclusion and 
static efficiency of the mental hospital and getting out into the field 
to do work for which they had little experience and learning many 
completely new applications of their basic knowledge and skill. In 
psychiatry there is so much ground to be covered that of necessity 
there has been a good deal of specialization. In Great Britain rather 
more than in America there has tended to be separation among the 
groups of men and women responsible for the different aspects of 
psychiatric work in mental hospitals and in mental-deficiency institu- 
tions, in psychopathic clinics and outpatient departments, in dealing 
primarily with the neuroses, whether by analytic methods or not, and 



THE FRONTIERS EXTEND 21 

in child psychiatry. Whilst these divisions have been far from com- 
plete they have been too marked and one effect of wartime experience 
for those who have been in the services is that these barriers are, we 
hope, permanently removed. Granted that on the top of a good person- 
ality, which is the first essential, the specialist has a sound foundation 
of general medicine and general psychiatry, every specialized interest 
and technique can be used in caring for the mental health of a com- 
munity such as the army. Whether the training has been in the main 
psychoanalytic, psychotherapcutic, or that of the orthodox mental 
hospital matters little. What is really important is that the psychia- 
trist should be a man who has a striking interest in his fellows and 
how they live, that he should have good psychiatric judgment and, 
above all, the ability to see behind the facade, what one might call 
some "feeling for depth" that something in the personality which 
is as important as any formal training for a psychodynamic approach 
to the task presented. It is not surprising that a number of good gen- 
eral physicians, general practitioners for the most part, should have 
shown that after several years of acquiring army experience as regi- 
mental medical officers they could appreciate and profit by com- 
paratively short psychiatric training and then become immensely 
valuable members of the psychiatric team. Naturally their value lies 
more in the wider sociological jobs of psychiatry, selection, etc., rather 
than in dealing with the more difficult and subtle problems of in- 
dividual diagnosis. The contribution of those with an analytic back- 
ground, who have also had the necessary stability and width of ap- 
proach, has been very considerable. Yet many men from routine 
mental-hospital jobs, whose acquaintance with dynamic psychology 
has been largely theoretical, have found that they, too, could play a 
very full part in the development of new and valuable work. The 
army, like the wider community, cannot always pick and choose and 
yet there is sufficient variety of work to allow for the use of every type 
of psychiatrist. Those well trained in modern methods of treatment 
of the psychoses, who have little interest in or knowledge of the 
psychoneuroses, function most efficiently in the psychiatric hospitals. 



22 THE SHAPING OF PSYCHIATRY BY WAR 

There always will be men who are primarily workers in institutions 
and who are far more suited to them than to the roving work of an 
"area psychiatrist," outpatient work or research and the develop- 
ment of new techniques in social psychiatry. In our choice of men for 
psychiatric work in the future we shall need to provide for all types 
and we can use them, but for the growing edges of psychiatry we shall 
need men and women with the qualities that have been hinted at 
above: stability, human interest and social curiosity. 

Doctors, unfortunately, come into the army ready-made and in the 
British army at present they are practically the only group of men 
or women who get direct commissions. The rest all come through 
the ranks and nowadays pass through the testing ground of the 
Officer Selection Boards so that there is a many-sided check on their 
quality and abilities. It is very regrettable that we, as doctors, should 
not have the same opportunity of selecting ourselves that the laity 
has, and it is still more regrettable that selection of men and women 
who are to begin their medical studies has not been made much more 
thorough, for that, after all, is one of the places where selection is of 
paramount importance. That the medical profession as a whole is 
moving towards the idea of wiser selection is illustrated by the fol- 
lowing quotation from the leading article of the British Medical 
Journal of the 27th May, 1944: 

It is a curious fact that until the advent of dynamic medical psychology, 
textbooks of "pure'* psychology were almost devoid of information or 
even of speculation about human motives. Knowledge of this kind has 
until recent years been reserved for men of the world. There is no reason, 
however, to suppose that this worldly wisdom cannot be comprehended 
scientifically, and more exactly and usefully. The scientific study of mo- 
tives, temperaments and attitudes is the subject matter of psychological 
medicine, which, beginning with the exaggerated and more easily de- 
tected processes of disease, is now, especially under the impact of war, 
coming to be concerned with the normal person and his aptness for 
special tasks, such as holding a commission or flying an aircraft; in brief, 
with "positive health" in the mental field, in the same way as general 



THE FRONTIERS EXTEND 23 

medicine is being stimulated in the maintenance of physical fitness. . . . 
It is of the utmost importance, if psychiatry is to play its proper part in 
building up and maintaining the health of the community, that it should 
attract recruits from among those with the best brains and the soundest 
character in the medical profession. 

Figures collected during the war give some grounds for thinking 
that the intelligence of the medical profession is not as high as it 
should be, enough grounds, at any rate, to justify the hope that serious 
investigation with absolutely valid samples will be made. There is a 
lot of evidence that medicine attracts people for various reasons which 
are not always conscious and that there is much instability and psycho- 
pathy amongst doctors. 

As the services have shown in every country, we in psychiatry can 
take a lead in this matter, and we must first set our own house in 
order and show that we really believe enough in the possibilities of 
thorough selection to start with ourselves. Later in the book there 
follows some description of the selection methods that have been 
developed in the British army, which constitute a considerable ad- 
vance on anything that has previously been attempted. 

SPECIAL TRAINING FOR PSYCHIATRISTS 

Whatever training, academic or practical, the psychiatrist has re- 
ceived before he comes into the army, it is our experience that his 
civilian skill and interests do not of themselves fit him to be of any- 
thing like his optimum value in the service without extra experience. 
Would that every doctor coming into a fighting service had to pass 
through the ranks and there learn something of army life and of 
the men for whom he will later be responsible, and the jobs they do. 
Where universal conscription holds, this situation is presumably met 
by the fact that every man has had a period of ordinary recruit service 
in the ranks. Since, however, psychiatrists like all other doctors are 
immediately granted commissioned rank, it has been found that 
their competence and value can be greatly enhanced by suitable plan- 



24 THE SHAPING OF PSYCHIATRY BY WAR 

ning of experience even in the short time that can be allowed. After 
the routine period at the depot, where some basic facts and elements 
of training are given to them, the men who are going into psychiatry 
go off for a month (it should be at least three) to serve an attachment 
to a combatant regiment. There they have no medical duties to per- 
form and their task is to learn as much as they can about the army. 

To fit in well with the men and with the officers is in itself some- 
thing that takes time. They should try their hand at all the routine and 
other tasks of the officers and men, so that they may have some better 
knowledge on which to assess the men's fitness for the future whether 
it be on marches, assault courses, humping shells, firing weapons, 
servicing guns, or indeed any other of the multifold occupations of 
the soldier in which they can share. After this period, which inci- 
dentally has a considerable effect (generally good) upon the opinion 
held of doctors and more particularly of psychiatrists by the officers 
and men he is mixing with, the trainee goes off as an apprentice to 
an experienced area psychiatrist so that he may learn all the various 
administrative methods and details and see where he can most use- 
fully fit in to the medical and administrative organization. He makes 
contacts with selection procedures of various types and learns how 
he can be of use to all the various agencies at work in any area for 
the training, welfare and education of the soldier. When he starts to 
operate on his own in some area he finds himself feeling really inside 
the army, understanding its point of view, difficulties and reactions, 
and without any question he makes a much more effective contribu- 
tion to the health and efficiency of the group in consequence. In civil 
life, save for the industrial medical officers, there are few doctors who 
to begin with have acquired much insight into the occupations and 
method of living of their patients. This comes with growing experi- 
ence but it may well be argued that comparable training could very 
well be introduced in the early stage of a man's professional career. It 
pays in the army : it would also pay in industrial or indeed any other 
civilian medical work. 



THE FRONTIERS EXTEND 25 

THE ATTITUDE TO PSYCHIATRY 

However good psychiatrists are, they will be criticized and at times 
very bitterly opposed. And this topic is of some interest and impor- 
tance in considering the development of psychiatry. The majority of 
valuable, constructive criticism of our work comes from nonmedical 
sources and with us at any rate in Great Britain the main part of the 
useless and purely destructive criticism seems to have come from 
members of the medical profession. This should certainly give us to 
think furiously about the question of medical education and closer 
co-operation between ourselves and our colleagues. 

The main opposition to selection procedures is based on the fact 
that the average man rather dislikes to have his phantasies destroyed. 
The commonest of all human daydreams is the Cinderella motif or, 
translated into military terms, the idea that every soldier has a Field 
Marshal's baton in his knapsack. Selection hits at this because it 
implies that someone can' demonstrate that this is in most cases not 
true. Many people object strongly to facing this reality even though 
it may be pointed out to them how much better it is to make full use 
in the best possible way of whatever intelligence and capacity they 
have got. The objection to psychiatry on the part of many doctors is 
somewhat similar. Medical training has in the past too often dis- 
missed the neuroses and indeed all psychiatric disability as something 
hardly worth studying, something which implied a weakness of char- 
acter, and the doctor who regards himself as a healer and is determined 
to cure people has to rationalize very heavily about his failure to cure 
emotional disorder with physical measures. Consequently he objects 
to those who seem to have rather better insight and perhaps a better 
therapeutic angle on these disorders. Our medical education in Great 
Britain more than in America has been unduly materialistic and at 
the same time bound up with financial considerations, and one might 
almost say the vested interests of private practice. No physician is 
likely to be very cordial towards a completely new line of attack on 



26 THE SHAPING OF PSYCHIATRY BY WAR 

disorders he has been working with until he begins to understand 
more fully and realize that he too can do rather more by a different 
and more personal approach to his patients. In the army we have a 
medical service in which all the profit motive is removed. No one 
bothers unduly about my patient and it is very noteworthy how people 
are ready to discuss and to learn and to try new methods. There has 
been much opposition to and intolerance of psychiatry but there is 
also greater receptivity, and considerable advances in postgraduate 
understanding of the psychiatric approach have been made as a result 
of the army medical service. If similar progress can be made in other 
branches of medicine and in the acquisition of new points of view 
and in the better assessment of the real value of medical procedures, 
then, truly, we have one argument for a state medical service. Psy- 
chiatrists, when they have the time to make the necessary contact 
with their general medical colleagues and with others responsible for 
the care and management of groups of men and women, have an 
educative function of no mean order and when we have the wit to 
see them we find an ever-increasing number of openings for the 
application of our knowledge. 

The psychiatrist is often a stimulator of other people. He should 
at no time be content with things as they are. Since he is trained to 
think all the time in terms of human reactions, it is he who is most 
likely to see and be able to demonstrate the emotional factors and 
attitudes that are at work or are to be expected in any organization. 
Just as we have aided the field of psychosomatic medicine, which has 
advanced much in recent years, so we bring contributions of value to 
very many of the medical and sociological problems of our colleagues. 
We ought to be stimulators, investigators and advisers. It is not the 
job of psychiatry to take over the work of other medical groups: it 
is our job to add whatever we can from the knowledge and insight 
that we have gained through our own psychiatric discipline. 

I am reminded of an amusing incident. An army psychiatrist had 
been attached to a military training staff to advise about the develop- 
ment of certain special techniques. After some time, and because 



THE FRONTIERS EXTEND 27 

there was a shortage of psychiatrists, I telephoned to the general with 
whose staff he was serving and said, "Surely you don't want a psychia- 
trist with you any longer now? He has done the best he can with the 
original job. I shall find it rather hard to explain why he is left with 
you." To my surprise the general replied, "For heaven's sake don't 
take him away. You simply can't think how useful he is to me. I often 
refer a dozen problems to him in the day. We regular soldiers get 
rather into grooves about many administrative and executive affairs 
and this chap, who is always thinking about what he calls the human 
factor, throws a most astonishing light on many of these problems. 
No, for heaven's sake, don't take him away." That, it seems to me, 
is symptomatic of what should occur with any good psychiatrist who 
happens to be in contact with men who are doing things. 

Psychiatry and psychiatrists, of course, get criticism from the com- 
batant soldier just as they must also meet opposition from the indus- 
trialist in civil life. Earlier in this present war we were often told that 
psychiatrists were the fifth columnists of the army, and this because 
they were advising the discharge of men who were obviously too dull 
or too unstable to soldier. The administrator who has to produce the 
"bodies" and is quite out of contact with real live men is critical, and 
much opprobrium has come to army psychiatrists because there has 
necessarily been a high discharge rate from psychiatric causes. The 
fighting soldier is in no doubt at all as to what kind of man he wishes 
to have with him. The further you get away from the front line the 
tougher become the comments, the more hints there are that everyone 
is trying to evade service, and that is and always has been a common 
experience of armies. To deal with a negative transference is a part 
of our trade and often it is the soundest basis for a good later relation- 
ship. Any suggestion of change may arouse anxiety and so aggres- 
sion, which the psychiatrist has to appreciate and counter, treating the 
situation clinically. Patience, jtolerance, infiltration tactics, and skill 
in counterattack, which psychiatrists learn through conditions like 
these, are of some value for the future. We cannot tolerate the reten- 
tion of sickness and inefficiency in society just because we wish to 



28 THE SHAPING OF PSYCHIATRY BY WAR 

avoid tiresome opposition and criticism of ourselves. It is very striking 
how few of the really intelligent and valuable leaders fail to appreciate 
the contribution of psychiatry, but we have to beware of those who 
become "converts" and thus lose their capacity to help us with real 
criticism. 

It will be gathered from this that psychiatry in the army is of special 
interest, not only because it is one of the toughest and fullest jobs and 
definitely related all the time to military efficiency and winning the 
war, but also because alongside the actual work with the men there 
goes this friendly running fight against opposition and a constant 
opportunity for discussion and mutual education. For most psychia- 
trists, army service provides a new angle to their job and the art of 
psychiatry itself becomes dynamic. 

THE PSYCHIATRIC OUTLOOK 

Before the war of 1914-18, in England at least, psychiatry was 
mainly of the descriptive type, kindly but somewhat mechanical and 
not as progressive as it might have been. The psychiatrist was in the 
main an alienist, and he usually called himself that. The small group 
of men and women who had heard about Freud were thought to be 
not quite respectable, and indeed, though they were attacked in the 
medical press, they were allowed no reply in those pages. The con- 
siderable incidence of battle neurosis in the war of 1914-18 shook 
psychiatry, and medicine as a whole, not a little. Valiant attempts 
were made to provide some respectable organic explanation for the 
curious phenomena which occurred with such frequency, and the 
term "shell shock" expressed the general belief that in some way these 
conditions were the result of structural disturbance. Fortunately there 
was a growing group of psychiatrists who provided the insight and 
understanding that were needed for these conditions, and not only 
were they wisely handled but the efficiency of their treatment in- 
creased steadily with the realization that these were the extreme and 
bizarre manifestations of emotional disorders in every way comparable 



THE FRONTIERS EXTEND 29 

in their mechanisms to those of civil life. That war finished with a 
very large number of neurotic men under treatment or drawing pen- 
sions some hundred thousand men costing ten million pounds a 
year and with a much awakened psychiatric conscience in Great 
Britain. 

Experience gained in the war and afterwards in the Ministry 
of Pensions' special hospitals and clinics for service men led to the 
establishment of clinics for civilians, and the realization grew that 
there was in fact a very large problem of civilian neurosis almost un- 
tackled. In Britain, the Lady Chichester Hospital at Hove was the 
only special hospital for neurosis before the last war. After the war, in 
1920, the Tavistock Clinic was founded for outpatient psychother- 
apy. The Maudsley Hospital, built before the war and then used as 
a military hospital, took on its full functions for civilians soon after- 
wards; the chair of psychiatry in Edinburgh was founded, and from 
then onwards an increasing number of clinics and special hospital 
outpatient departments were opened. Many of the clinics were started 
at the instigation of the Board of Control, an official body. Post- 
graduate medical education improved steadily and medicine began 
to think of neurosis as real illness (not just imaginary illness) and 
also as something that could be treated. The orthodox psychoanalytic 
group was somewhat apart. Its work and its teaching were nevertheless 
all the time permeating the various groups in psychiatry. Out of war 
does come some good, and psychiatry in Great Britain owes a good 
deal to the experience of 1914-18. The War Office Committee on 
Shell Shock, whose Report was published in 1922, gave an extremely 
good summary of the whole situation. They brought together a great 
many facts, set out very clearly and convincingly the nature of 
the problem, and suggested prophylactic steps and the remedies that 
should be prepared should such a situation ever arise again. Unfortu- 
nately, as Hegel says, "we learn from history that we don't learn from 
history." Very little was done by the army to utilize this experience 
and to implement the recommendations of their own committee in 
preparation for this war. But the country as a whole through the 



3 o THE SHAPING OF PSYCHIATRY BY WAR 

medical profession benefited very greatly from that mass experience 
of neurosis. 

This is not the place to attempt to set down an exact record of the 
developments in psychiatry in Great Britain, let alone in America, 
but these two decades between the wars have been a time of steady 
progress. Descriptive psychiatry has done more than flirt with psycho- 
dynamic concepts, though I would hesitate to say that their marriage 
had been finally accomplished and duly blessed. We in Great Britain 
are often inclined to feel that we lag some way behind you in psychia- 
try. You in the United States have certainly given us many leaders 
and you have bred a very outstanding race of teachers and writers. I 
suppose it is true that America will try anything once that is what 
we are always told; if that be so it may explain why you were much 
readier than your Allies to explore and try out the psychodynamic 
concepts of illness. Then, I suppose, finding that they worked, you 
went on and ahead. In 1930, at the Mental Hygiene Congress in Wash- 
ington, I remember being surprised when one night I found myself 
sitting with seven or eight very senior colleagues, all superintendents 
of state institutions, who were discussing psychoanalysis and certain 
possible applications of the theory and method to their own work. I 
certainly felt, and I was right, that it would have been difficult to find 
an exactly comparable group in Great Britain at that time. It would 
be quite wrong if I gave an impression of decrying British psychiatry, 
and I certainly do not in fact do so. I would be quite prepared to take 
a chance in putting up a true random sample of superintendents and 
other psychiatrists from America and one from Great Britain and 
comparing them! Nevertheless, I think it is true that you did make 
greater and more rapid strides in integrating analytic concepts into 
your psychiatric knowledge, and I suspect, though I have no proof, 
that this resulted partly from the impact of the last war on American 
medicine. 



THE FRONTIERS EXTEND 31 

THE SOCIOLOGICAL APPROACH 

No doubt some of you have done what I did many years ago in a 
flush of enthusiasm for the methods of analytic psychotherapy which 
I still have. 1 took the most reliable figures and estimates of the num- 
ber of neurotic or maladjusted men, women and children in Great 
Britain, say approximately three million, who were in need of treat- 
ment and worked out how many trained psychotherapists would be 
necessary to deal with the whole of this group spread over, say, a 
five-year period. The number of hours of medical time given to each 
patient was taken as round about twenty, a figure which is slightly 
below the prewar average of time given at the Tavistock Clinic. If 
you care to work out the figure yourself, you will find that the result 
is somewhat horrifying and quite ludicrous. If you assume that the 
psychoanalytic method is the only one which gives good results, then 
the calculation becomes astronomical. Because many people have 
given some thought to matters like this, the emphasis has been in- 
creasingly laid upon the need for rapid treatment, group treatment 
and above all prophylaxis; and many of us were looking for light on 
these problems long before the present war. The great work of Wil- 
liam Healy, who seemed before the last war to have taken Samuel 
Butler's Erewhon quite seriously, helped to point the way for many 
of us not only to methods of tackling child delinquency but also to 
the handling of the much wider problem of maladjustment and 
psychiatric disorder in children. This clearly was the best form of 
prophylaxis and the soundest method of achieving a community with 
better mental health. In Great Britain child psychiatry grew out of 
this quickened interest in the neuroses after the last war and as a 
matter of fact the first patient seen in 1920 in the clinic with which 
I am associated was in the Children's Department. This work grew 
because it gave obviously satisfactory results, much more easy to 
follow up than in any group of adults, and very speedily the educa- 
tionalists, social-care organizations, the courts and other responsible 
bodies began to register their interest in the matter. They showed 



32 THE SHAPING OF PSYCHIATRY BY WAR 

that they were even more alive to its value than the parents of the 
children and at that time certainly more than the medical profession. 
The American child guidance movement and the Commonwealth 
Fund provided us with much further stimulus, trained workers and 
funds for further experimental clinics. Child psychiatry became estab- 
lished and has never looked back; probably it is in fact the most 
important contribution to health that psychiatry has made in this 
century. The social worker and the psychologist began here to dem- 
onstrate how great a contribution they had to make to the solution of 
the problems and we owe much of our growing interest in the socio- 
logical and psychological aspects of our work to children's psychiatric 
clinics. It has often occurred to me during this war how adequate 
a machine this child guidance team has been. Quite unconsciously 
the organization of the War Office Selection Boards for officers in 
the British army, of which I shall have more to say later, has turned 
out to be on exactly parallel lines. Here also there is a team: a psychia- 
trist, a psychologist, and the regimental officer whose function is more 
sociological than strictly military. There are many other instances 
that could be quoted from the British army and from our Allies which 
demonstrate the value of this threefold approach and provide con- 
firmation that the teamwork method begun for children, and de- 
veloped increasingly in the soluti9n of adult problems, is applicable 
in a still wider way for the future, in which we shall have so many 
tangles to unravel and such massive readjustments needing our help. 
The sociological approach to psychiatry had been carried further in 
the United States than in Great Britain though there the work of the 
Industrial Health Research Board, notably that of Millais Culpin and 
May Smith, demonstrated the value of environmental and statistical 
studies in the appreciation ahd solution of problems of neurotic ill- 
health. In America you were better endowed with industrial psychol- 
ogists and with sociological workers and even teams of workers who 
have made most striking contributions to our understanding of group 
structure and of interpersonal relationships. They have shown that, 
by and large, emotional difficulties which lead to mental ill-health, 



THE FRONTIERS EXTEND 33 

suffering and inefficiency are to be regarded not merely as individual 
matters but rather as an expression of group maladjustment. It has 
been interesting to note before the war, and still more during the 
war, how sterile sociology is without a psychodynamic or clinical 
approach, and what striking illumination it can throw upon problems 
of the greatest importance in the hands of those who have this concept 
and method. 

THE PSYCHOLOGIST IN SOCIAL MEDICINE 

It was not, of course, from child guidance work that the real im- 
portance of the psychologist in our field became evident. It seems 
certain that we owe that advance in the main to the experience of the 
last war and in particular to the courageous experiments of the United 
States army during that war. From having a somewhat limited func- 
tion, psychology became suddenly a weapon of war, a method by 
which the efficiency of the fighting force could be improved, the in- 
terests of the individual better served and the health of the com- 
munity in certain ways safeguarded. Testing for intelligence and 
aptitude was not new, selection of armies was not new, for even 
Gideon carried this out most effectively (Judges, 7: 1-7). 

What was new was the particular application of modern psycho- 
logical methods to help in the choosing of a great civilian army. It 
was the first time in which it was demonstrated that the application 
of selection methods to really large groups was a possibility and, as 
we know from the records, it was in very many ways an outstanding 
success. There were a number of derivatives from this procedure. In 
the first place, in the United States, it naturally led to an increased 
interest in personnel selection and in the methods of industrial psychol- 
ogy. Outstanding work has been done in this country, and the whole 
world is in the debt of the United States for the practical outcome of 
your psychological work, whether it be in industry, as for instance 
the Western Electric experiments, in personality delineation, or in the 
larger studies of social groups. The war had stirred up so much in- 



34 THE SHAPING OF PSYCHIATRY BY WAR 

terest that you had more trained workers and more appreciation. 
Industrialists were readier to accept, to help and to support the experi- 
ments of industrial psychology. This war is likely to produce still 
further advances and some of them will derive from the very close 
co-operation which exists between psychologists and psychiatrists, a 
fruitful union for the study of all the group problems. 

Germany borrowed much of your last war work and built on it the 
psychological department with its elaborate selection techniques, out 
of which grew the still wider department of psychological warfare. 
However disastrous the ultimate aim and purpose of this work in 
Germany, there is no question that it was thorough and effective 
though lacking in some of the more imaginative and insightful aspects 
of work in our own countries. 

We in Great Britain have also used the United States* experience 
and as you have in this war I hope we also have improved on it. 
Without any question the value of the psychologist in war has been 
demonstrated so clearly that in peace there will be no question that 
his help will be demanded. With certain notable exceptions Great 
Britain has not produced all that it might have done in the field of 
psychology. Some of our older universities still insist that it shall be 
classed as "moral philosophy," our university laboratories have been 
neither well equipped nor adequately endowed, and there was in 
general little support for the adventurously minded industrial and 
vocational psychologists such as were trained by the National In- 
stitute of Industrial Psychology in London. At the beginning of this 
war we were much harder put to it than America could have been 
for suitably trained men of the right calibre to work for the fighting 
services. All this must change when peace comes. 

I have always thought that the four professions most liable to be 
chosen by those with marked feelings of inferiority are the law, the 
church, teaching and medicine, all professions in which you can 
talk down to people and in which they can't answer back. It may be 
for some reason like this that medicine as a whole has been somewhat 
superior and exclusive and unwilling to align itself on any basis of 



THE FRONTIERS EXTEND 35 

equality or even thorough co-operation with other groups such 
as psychologists and sociologists whose disciplines are fully as ex- 
acting. 

It is still true of medical men as a whole, and even of psychiatrists, 
that they are only prepared to accept limited help from psychologists, 
and that in the role of technical assistants. Partly this arises, in Great 
Britain at any rate, from the shortage of well-qualified, competent 
psychologists, but there are deeper emotional reasons operative at 
the same time. Psychology has a wide field to cover and in many of 
its functions there is little of medical interest, but in the educational 
and industrial fields especially there is no part of psychological work 
which is not a direct contribution to an efficient system of social 
medicine and willy-nilly the psychologist is an operative in our health 
services along with the medical man. In Great Britain it seems certain 
that, as a result of the close co-operation between psychiatrists and 
psychologists and the growing appreciation by general physicians and 
others of the valuable contributions made by the psychologists, there 
will be a close liaison between our two groups which will be of the 
greatest value to both. From the psychiatrist especially, the psychol- 
ogist will learn something more about men and motives and the 
psychodynamic forces at work in the subjects of his enquiries. From 
the psychologist, medicine can learn much of the scientific and statis- 
tical approach to problems of ill-health and can apply to prophylaxis 
and to the improvement of therapy many of the facts disclosed by 
psychological investigation. Psychology is not to the psychiatrist just as 
physiology is to every doctor. It occupies a more forward and strategic 
position in the struggle for health. In the army in Canada the integra- 
tion of the psychologists with medicine is almost complete, and this 
would seem to be a very farseeing and valuable arrangement since it 
ensures maximum co-operation and assures the freedom of a tech- 
nical subject from undue administrative interference, a point of no 
little importance as all technicians who have suffered from, instead of 
being able to work with, administrators are aware. Some part of this 
difficulty between doctors and psychologists will disappear with im- 



36 THE SHAPING OF PSYCHIATRY BY WAR 

proved undergraduate education and especially with better psycho- 
logical and psychiatric training. Some part of the general medical 
attitude is, of course, based upon ignorance of what the psychologist 
claims and does not claim and what he is able or unable to perform. 
Early in 1939 a fairly complete scheme was suggested for the selection 
of men to be called up for the militia in Britain prior to the outbreak 
of war. The scheme was put forward to the medical authorities of the 
army but was rejected completely and when eventually selection was 
begun systematically two years later it was brought in at the instiga- 
tion of the administrative side and was not within the medical field. 
Similarly objections to selection, based on a complete failure to under- 
stand its part in social medicine, were advanced by those responsible 
for the civilian recruiting boards in Great Britain. Somehow or other 
we must learn from such experiences and from the wastage which 
occurred because of this action. The future will present us with many 
parallel situations and it is important that we should be armed with 
the necessary arguments to carry conviction and so allow for wiser 
planning. 

Reverting for a moment to the concept of medical services becom- 
ing in fact health services in the future, there is growing evidence 
produced by war experience of the need for expansion of our ranks. 
Physiologists, entomologists, chemists and other scientists have for 
long enough been regarded as part of the team. From now on we 
shall need sociologists and welfare workers, and by this is implied 
something rather more than social work or the medical social services 
of hospitals. Welfare is essentially a medical weapon and must concern 
itself with all manner of social phenomena: the welfare aspect of 
medicine will lead us into the political and governmental field in- 
evitably and it is right that we should go there. Sometimes one aspect 
of the subject will be to the fore and consequently one member of the 
team must be in the lead. Just as in selection procedures where group 
sorting is concerned, the psychiatrist tends to be the handmaid of 
the psychologist, while in more detailed selection where personality 
is concerned the position is reversed, so the internist or the surgeon 



THE FRONTIERS EXTEND 37 

will clearly be in the lead in some aspects of our work, the sociologist 
in others. It may take time to achieve a proper synthesis of these 
various groups into the health services of the future but we at least 
know from experience in the services that this team method works 
and produces the results we seek. As psychiatrists we have a special 
responsibility to consider and take action about changes of this kind 
and if we take off the blinkers of our individualist civilian practice 
there will be few of us who do not see the necessity and welcome the 
opportunity of much fuller co-operation with other adequately trained 
nonmedical workers. 



MAKING PSYCHIATRY WORK 

It is not yet quite clear whether the actual treatment methods of 
the psychiatrist have developed very much in this war. Certainly in 
my experience the treatment of the psychoses has not produced any- 
thing new. This is not at all a large or important group of disorders 
in the army. The most that one can say about it is that in a community 
organized as the army is we have the chance of getting our patients 
under treatment a good deal earlier than often happens in civil life 
and that consequently the results of various forms of active therapy 
are somewhat better. A surprisingly good record of recoveries is re- 
ported from all armies as far as I know. In thinking of the treatment 
of the psychoneuroses we must of course divide them into two groups, 
the chronic and the acute. The chronic neuroses, of which there is a 
very large group, have to be treated, though in many cases they may 
be only returned to limited service or even be going out of the army. 
Methods of group therapy have been devised which are some slight 
advance on those utilized before the war. Occupational therapy has 
tended more and more to develop along paramilitary lines since we 
recognize that, for resocialization of a man, some occupation which 
sends him out of the hospital a more efficient soldier than he was when 
he came in is likely to be of greater value than the more standard occu- 
pations employed for long-term bed cases. The battle neuroses have 



38 THE SHAPING OF PSYCHIATRY BY WAR 

been treated effectively. There has been a tendency to move away 
from straight persuasion and hypnosis to the chemical methods of 
sedation, narco-analysis and modified insulin therapy, but the results 
as judged by returns to duty are little or no better than they were in 
the last war, although possibly the long-term results may be better. 
For this work we owe much to Sargant, Slater and other workers in 
the English Emergency Medical Service. Where most progress has 
been made is along lines of prophylaxis. Selection methods have im- 
proved and a far greater variety of special disposals have been de- 
veloped which enable us to keep men relatively fit and to avoid break- 
down in others. 

In order to carry out such procedures not only have we had to 
indoctrinate and educate regimental officers, administrators and med- 
ical officers, but we have had to learn a good deal about administra- 
tion. Medical men as a rule are bored with administration. They may 
resent it, they may be contemptuous of it, but in fact an interest in 
and a knowledge of administrative techniques are a very effective part 
of our armamentarium. To know what can be done with a man and 
then, still more important, how our advice is to be implemented is 
obviously of value. To be a recognized expert in how any particular 
object can be achieved is as good for our patients* morale as it is for 
our own reputations. If we take administrative procedures seriously 
and become expert in using them, we find that the people we co- 
operate with respect us, and not only can we do more for our patients 
but we can begin to give help in the shaping of policies which affect 
them and which affect the efficiency of the whole group. Our help is 
welcomed, whereas the well-meaning suggestions of the amateur are 
not often received with applause. The administrator is, of course, 
often a difficult man, someone, who may possibly be running away 
from real life and real people. This may even occur if the administra- 
tor happens to be a psychiatrist though that should never be so! To 
work together with the administrator, and to show oneself as knowl- 
edgeable and competent as he is, puts us in the strongest possible posi- 
tion to pull our weight in social psychiatry. In army psychiatry this is 



THE FRONTIERS EXTEND 39 

proven, and again it is suggested that the parallel should hold be- 
tween the services and civil life. 

Possibly some of those who up to date have been primarily inter- 
ested in individual clinical problems may find it hard to realize that 
satisfactory work in curative medicine can be done through adminis- 
trative channels by social and vocational adjustment. Certainly those 
who have worked in child guidance will not be amongst this number, 
and in fact few of us should be because from our patients we all have 
acquired experience of better health resulting from changes of this 
sort, whether these changes were the result of diagnosis and prescrip- 
tion or merely a matter of chance. One of our tasks is to discover 
whether in fact this is for certain groups the method of choice in 
treatment or whether it is merely a second best. It is worth giving 
one or two examples of what has been tried in the army since they 
may make some contribution to the solution of this question. 

Early in the war a large number of men with chronic neuroses, 
those who were constitutionally predisposed, were breaking down 
and had to be discharged from the service. Many of them were com- 
petent and able people who clearly had some contribution to make 
to the army in war if they could be kept stable and fit. One experi- 
ment was tried by which men of this type were drafted into labour 
companies whose entire job was agricultural. The farmers through- 
out England and the agricultural committees responsible for improv- 
ing the output of the land were very short of labour so that agricul- 
tural work, for the most part unskilled, was not only welcomed but 
was a matter of some importance and was easily comprehended as a 
real contribution to the war effort. These agricultural companies were 
run on a basis of military discipline less strict than the normal. So far 
as possible men were allowed to make visits to their homes at week 
ends and excellent welfare was provided for them. The result was 
that where men had been reasonably well selected for this job they 
did good work, went sick very little and had good morale. For various 
reasons, chief amongst them being that the companies were very 
restricted in the nature of their work and that the army needed greater 



4 o THE SHAPING OF PSYCHIATRY BY WAR 

fluidity, this experiment came to an end. It did not produce cures, 
as some optimists had hoped it might, but it did provide work and 
an environment that allowed the neurotic men to contribute without 
coming under greater stress. It is perhaps worth noting for our post- 
war problems that here is further evidence that the return to beautiful 
surroundings and to mother earth does not produce cure of war 
neurosis. It will be tried again and will be said to work, for it is a 
very popular piece of homeopathic magic. Nevertheless its therapeutic 
dividend is negligible. 

An arrangement was then made for men who, after treatment in 
special neurosis centres, were felt to be unfit to return to military duty 
except in some special occupation to have that particular job found 
for them. Under this scheme each hospital concerned had the power 
of direct access to the posting department of the War Office that was 
responsible. Careful assessments were made of the men's capabilities 
and more or less specific suggestions were made as to the jobs they 
could best do. Often this was something in keeping with the man's 
prewar occupation or perhaps was related to his hobbies or spare- 
time skills. Such postings, whether to specified units or to individual 
extraregimental employment, could only be varied on the authority 
of the War Office and after further psychiatric examination. That 
experiment turned out well and the follow-up showed that 50 per cent 
of the very large number of men so treated have continued to give 
good service in their new work, neither going sick nor giving rise 
to any disciplinary troubles. In addition, they were happy. An in- 
dividual follow-up and recheck of a large random sample of these 
men confirmed these findings, and brought up one or two other 
factors of importance. In the earlier months of the working of the 
scheme, it was thought that these men were more likely to remain 
stable if posted to the vicinity of their homes and in consequence this 
was arranged. That turned out not to have been in any way related 
to the success of the experiment, whereas it was quite clear that a 
chief factor in successful adjustment is that the man's work is within 
his competence and something of which he can feel proud: in other 



THE FRONTIERS EXTEND 41 

words, we come here, as in many other places, on to one of the car- 
dinal secrets of good morale. The other point that has been demon- 
strated is that those neurotic men who at the same time have poor 
intelligence, or as the army calls it a "low capacity to learn," do less 
well than the more intelligent group. The men who on intelligence 
testing fall into the bottom 30 per cent of the whole population group, 
do not repay allocation to specific employment in this way within 
the framework of the army though they can often be well used for 
manual labor. This experiment is not only of considerable importance 
in that it has helped to maintain the manpower of the army and to 
ensure that certain jobs are well done by men whose employability 
is limited, so releasing other fitter men, but also it should be of some 
value to us in planning for the treatment and disposal of the chron- 
ically neurotic men and women in civilian life. 

This ability to make some approximate grouping of men and 
women in the services according to their intelligence has helped us 
to the solution of dozens of problems within the services. When the 
Auxiliary Territorial Service, that is, the women's service of the army, 
began to expand, some light was thrown on one of their tiresome 
problems in a particular locality, that of infestations of the hair. The 
correlation of nits in the hair with low intelligence is significant and 
whilst common sense tells us that the woman of low intelligence will 
take less care of herself than her brighter sister, some statistical proof 
is needed before administrative action can be taken to put a limit on 
the intelligence groups which may be accepted for service in wartime, 

TABLE I 

Infestation with Head Lice among Women Army Recruits 

Intelligence Groups * 

12 3+ 3- 4 5 Total 

Total recruits 23 171 268 348 502 264 1,576 

Infested recruits o 12 49 79 182 120 442 

Percentage infested o 7% 18% 23% 36% 45% 28% 

* In this study, which was made before the introduction of routine selection procedure 
in the army, the percentilc limits of the groups differed from those now set for the 
army selection groups. 



42 THE SHAPING OF PSYCHIATRY BY WAR 

Similarly the problem of scabies has been related to intelligence. 
Lieutenant Colonel G. R. Hargreaves collected details of the intelli- 
gence levels and incidence of scabies in thirty thousand consecutive 
army recruits. In Table 2 which follows, the intelligence levels 
are shown by selection groups (SG). SGi-the top 10 per cent; 
SG 2 = the next 20 per cent, etc.; whilst SG 5 = the lowest 10 per cent. 
Here again we have some statistical demonstration of the disease 
problems which are associated with poor intelligence. 

TABLE 2 

Scabies and Intelligence Level 

Strength of Intakes 

Scabietic Recruits By SG's Percentage 

SG i 21 3,945 0.53 

SG 2 65 6,983 0,93 

SG 3+ 109 9,389 1.16 

SG 3- 89 8,346 1.07 

SG 4 123 6,565 1.87 

SG 5 46 2,102 2.19 

Total 453 37,330 1.214 

INADEQUATE MEN 

It would be ideal if every man taken into the army to fight or to 
service those who fill the front line could be entirely fit and have an 
I.Q. well over 100. Where manpower is easier to come by, as in the 
United States, the standards for acceptance have been very much 
higher than we have been able to make them in a country like Britain 
at a time when the demands from the other fighting services, the 
civil defence services and industry, have been so insistent. We have 
had to use our dull men and, in fact, we have been able after much 
tribulation to do so very effectively. The ascertainment of the defective 
and the dullard in civil life is by no means perfect, and the group 
intelligence testing carried out by our Directorate for the Selection 
of Personnel in the British army has consequently been of the utmost 
value in bringing these men up for psychiatric examination at the 



THE FRONTIERS EXTEND 43 

beginning of their service careers. Where dull men had been incor- 
porated into units either prewar in the regular army or in the early 
days of the war, they often turned out, of course, to be problems. A 
static unit when in training can carry quite a number of dullards by 
increasing the number of its "stooge" jobs. Only when it has to pre- 
pare for active service are these men extruded, either by off-loading 
them on to other units or by some other means equally undesirable 
and wasteful. 

There has been a popular tradition in the past that the dull man 
made a good soldier, and where he could have lengthy, careful train- 
ing in a peacetime army this certainly was often so. The stresses of 
war and its increased tempo make this next to impossible. Whilst the 
armoured corps must have the bulk of its men over the median in 
intelligence, the modern infantry also demands men of high intelli- 
gence, for they have so many weapons to learn and so many skills to 
master that an impossible task is presented to the dull man. The 
dullard amongst men of higher intelligence begins quickly to feel 
himself inferior and from this he develops anxiety; he may break 
down or he may malinger, and it is of interest to note that while 
malingering is extremely uncommon in this war most of what there 
has been has occurred in dull men, looking for a way out of what is 
to them an intolerable situation, through conscious exaggeration of 
some minor disability. Because he doesn't comprehend at all easily 
the dullard disobeys or ignores regulations and becomes a disciplinary 
problem to his unit. A high proportion of absence without leave, 
which is the commonest army crime, occurs in dull men. The dullard 
becomes therefore in modern war a consumer of manpower rather 
than a contributor. The bill for instructors' time, orderly room time, 
courts-martial, record offices, hospitals, etc., which is run up by dull 
men wrongly placed in the service, though it has never been specif- 
ically computed so far as I know, is certainly very great. In civil life 
we do at least know that the bulk of chronic sickness and of recidivism 
comes from a very small section of the population. This is the con- 
stitutionally inferior group, the psychopathic tenth of the community, 



44 THE SHAPING OF PSYCHIATRY BY WAR 

and again its cost to the country is something which needs to be 
demonstrated. In the last war, as a result of the selection procedures 
of the United States army, you showed us that your worst soldiers 
were potentially your best diggers. Learning from your experience 
we advanced this argument, not only quoting your phrase but 
copying your histograms, in the attempt to get prewar selection 
started. 

Later, when we were faced with considerable numbers of these back- 
ward men, we made many attempts to get them utilized in suitable 
occupations, and finally reached a very successful result. We have now 
established sections of our Pioneer Corps which are unarmed. They 
are limited to men whose capacity to learn is so low that although 
they are reasonably stable emotionally, or likely to become so on 
transfer to labour duties, they are not safe to be armed. Certainly they 
could not profitably be armed or trained for fighting. The less dull, 
who can bear arms for purposes of self-defence, find their best niche 
in the ordinary armed Pioneer companies. Every man in these un- 
armed sections has been investigated psychiatrically, for all those who 
fall into the lower selection group on the intelligence tests are auto- 
matically referred to a psychiatrist for advice as to disposal. Some 
clearly are unable to be retained in the service at all, but an increasing 
number are valuably drafted to the Pioneer Corps, and the standard 
of understanding care given to them by the NCO's and officers has 
steadily risen. 

Because this problem of the dullard the one-job man has been 
insufficiently recognized even by psychiatrists in civil life, these men 
have tended to form a social problem group. During the war in 
Britain, hostels for civilian men of this type doing agricultural work 
have been started and their success has apparently been very com- 
parable to the good results of the unarmed Pioneers. These results 
are, in fact, striking. Living and working together in a community, 
these men easily find friends of their own intellectual level. In peace- 
time, because they are dull, they are lonely and relatively friendless. 
Too often the tendency for them is from sheer loneliness to find the 
companionship of some woman, a dull woman, and bv her thev mav 



THE FRONTIERS EXTEND 45 

have a large family of defective children. It seems at least probable 
that the defective is more properly to be regarded as a lonely person 
wanting affection than someone with a strong sexuality. Indeed the 
work of Wittkower on proneness to venereal disease has shown 
clearly that in the man of average intelligence this is also true. It is 
presumably, too, a fact to be borne in mind with coloured men. Largely 
because these men make friends in the special units, they have very 
few sexual difficulties and they have very little army crime. In fact, 
the health records and the crime records compare very favourably 
with those of the best units of the field force. Their work is excellent, 
because they are intensely proud of the contribution they are able to 
make to the war. Once again, their job road making, hut erection, 
humping shells, or whatever it may be is well within their com- 
petence. So often one hears the man who has been sent up by his 
unit as a problem say, 'Tm no scholar, sir. Can't I have a pick and 
shovel?" The army is concerned with groups, but it also rubs into 
most of us the need of still greater respect for the individual, be he 
a university don or a dull manual labourer. Experiments such as this 
one that I have been describing open up the whole question of whether 
our provision for this handicapped section of the community should 
not be made much more comprehensive. There are few aspects of 
social medicine more important than this. Aldous Huxley in his book 
Brave New World was planning to produce a section of subnormal 
men who would do the dull jobs of the community: we don't really 
need to produce them for there are too many already. If we can employ 
them, and if we care for their morale, i.e. their mental health, there 
will be fewer of them and as a group they will be contributors to the 
life of the community and not consumers or problem makers. 

PRIORITIES IN OUR WORK 

Having given two or three instances of therapeutic techniques 
which depend upon administrative action it may be of some interest 
to emphasize the types of problem that are met in a society such as 
the army, nearly all of which demand understanding, handling and 



46 THE SHAPING OF PSYCHIATRY BY WAR 

Table 3 which follows gives some hint of the various disposal prob- 
lems which arise. 



TABLE 3 

Disposal of Psychiatric Cases from Army * 

Neuro- 
sis and 

Psycho- 
pathic Mental Other 



Person- 
ality 

i5>995 



19,331 
9> 2 44 

3 I 47 
1,692 

15*583 



)ullncss 
r Defect 


Psycho- 
sis 


Diag- 
nosis 


Total 


Per 
Cent 


13,964 


162 


13,252 


43.373 


19.24 


-.534 


126 


2,702 


21,401 


9.48 


105 


228 


362 


20,026 


8.87 


3i 


81 


107 


9.463 


4.19 


144 
59 


5,872 
214 


216 

866 


9.379 
2,831 


4.15 
7.25 



320 



56 359 16,318 



Recommendation 

Returned to unit, 
no action 
For observation in 
unit or OP treat- 
ment 

To EMS (civilian 
neurosis centre) 
To military neuro- 
sis centre 

To military mental 
hospital 

To other hospitals 
Reduction in medi- 
cal category 
Transfer to labour- 
ing and manual 
work, armed and 
unarmed (5 classes 
of disposal) 
Other methods of 
disposal; change of 
employment, etc. 
with or without re- 
duction of category 
Discharge 

Total 
Per Cent 

* Table showing the figures of a scries of outpatient consultations on patients re- 
ferred by medical officers to area psychiatrists. These figures do not cover patients 
seen from army intakes, selection testing, army selection (misfit) centres, officer selec- 
tion boards or psychiatric hospitals. 



1,950 26,757 406 419 29,532 75.09 



20,056 
26,275 


11,885 
6,742 


335 

445 


6,616 
1,000 


38,892 
34,462 


77.2^ 


130,312 
(5775) 


6l,45I 
(27.26) 


79 2 5 
0-5') 


25,899 

(11.48) 


225,677 


700.0 



THE FRONTIERS EXTEND 



47 



These figures relate merely to outpatient consultation work of area 
psychiatrists in the British army at home. Perhaps they are in con- 
sequence as near as the army can get to comparable figures for civilian 
life. They indicate the psychiatric problems arising in the ordinary 
recruit or serving soldier and omit any figures which might be given 
from special selection centres for misfits or returned invalids from 
overseas. There are certain points that illustrate the difficulties which 
face the psychiatrist and also the amount he needs to know. For 
example many men are returned to their units: it is clearly necessary 
to assess whether one particular man from any one of the many 
specialized units is in fact fit for the actual work he will be asked to 
undertake, and this decision has to be made quite apart from the 
prognostic aspect of the question as to whether he is going to improve 
or deteriorate as a result of living and working in a particular environ- 
ment. The question of the correct medical category is vitally impor- 
tant in the army since it determines the type of unit to which a man 
will be posted, the duties on which he will be employed and where 
he will serve whether in battle, on the lines of communication or 
at the base, whether overseas or at home. The problem of the psy- 
chiatric disorders is considerable in this matter and it is partly for 
this reason that the British army is beginning to adopt, even at this 
stage of the war, the PULHEMS System devised in the Canadian 
army, by which a profile assessment is made of each man Physique: 
Upper-limb function, Lower-limb function; Hearing; Eyesight; 
Mental capacity (i.e. intelligence); and Stability. Under each letter 
a number is given to him, from i to 5, indicating his grading, so 
that the man in every way perfect would be i, i, i, i, i, i, i, whereas 
the man who, let us say, is perfect in every way except that he had 
suffered from some stress anxieties might be i, r, i, i, i, i, 3. The 
employability of the man who has certain limitations is much more 
satisfactorily decided by such a profile than by any of the older and 
simpler methods of categorization which have been in use. 

The psychiatrist sees not only those who score low in an intelli- 
gence test, but any other men or women from the army intake 



48 THE SHAPING OF PSYCHIATRY BY WAR 

whom the personnel selection officers think may possibly be unstable 
or in some way unusual from a psychological point of view. This is 
of the greatest importance in Great Britain because there are no 
routine psychiatric examinations on the National Service Recruiting 
Boards which pass men medically for the services. These are civilian 
boards run by the Ministry of Labour. In an average intake to the 
army, the psychiatrists may be asked to see perhaps from 14 to 15 
per cent of the whole intake and to advise about disposal or posting 
and occasionally, of course, hospitalization. 

It will be noted from the table of outpatient figures how small a part 
of the problem is constituted by the psychoses. That a considerable 
number of these men are dealt with not by discharge but by reduction 
of category, change of arm, etc. is explained by the number of reactive 
depressions which clear up. These have to be coded as psychoses. To 
some extent, of course, the group of men going into the army is 
selected, but even in civilian life the psychoses are but a small fraction 
of the problems that face us in psychiatry. It is a good thing that 
groups of figures like these should keep us reminded of the fact that 
the bulk of our work lies, or should lie, outside institutions. Psychiatry 
has in the past had so many vested interests in its enormous mental 
hospitals, and the patients have in these hospitals, in fact, constituted 
so large an institutional problem that it has been all too easy to over- 
look the fact that this costly group of humanity was but a tiny sample 
of the mentally sick and that our undergraduate and postgraduate 
training must be oriented more and more towards the wider problem. 

I suppose that all the world over, as in Great Britain, the word 
"priority" comes to the fore in wartime. All sorts of lists of priorities 
are prepared, and this approach has to be made to problems of pro- 
duction and supply and many other aspects of war organization. It 
might be worth while if we made rather more use of the idea of 
priorities for our peacetime work, for it has some value. It is clear, 
even from the figures in Table 3, that in an army the psychotics are 
of low priority in importance. There are few o them, and in any 
case practically none of them are ever likely to get back into the line to 



THE FRONTIERS EXTEND 49 

fight, however valuable they may be in civilian life. Similarly, treat- 
ment of the emotional disorders has a fairly low priority for just the 
same reasons although treatment of acute battle neurosis behind the 
lines is a matter of high priority since manpower is saved through 
such therapeutic provision. We have tended to give highest psychiat- 
ric priority to selection of all kinds, in other words the provision of 
the right material and the attempt to ensure that it is used in the 
right way. Our second priority has been prophylaxis, whether that 
consisted of better training methods or better officer-man relationship 
and "man management" as the British army likes to call it. The study 
of morale and its maintenance in various ways has been third on the 
list. In the present stage of the war, treatment which was low in the 
list has come further up in our judgment and has much higher priority 
since we are being faced by much more acute breakdown and also 
by the prospect of the return of men from overseas with varying 
degrees of mental unfitness which need treatment of some type. 

If we are planning for better health facilities for everyone and for 
an A i population, should we not be thinking for civil life in terms of 
the importance and value to the group of some of our patients? A 
very disproportionate amount of time and effort is often expended 
upon people whose clinical condition may be interesting but who arc 
of little value to the community, and insufficient effort is made to 
deal with the larger groups of people with less bizarre psychological 
disorders who are potentially highly important from a social point of 
view. 

As we look rather sketchily at some of the ways in which psychia- 
try has occupied itself in the army, it is clear that our values are chang- 
ing and are bound to go on changing and growing still more in the 
future. The points that have been touched on and those that are men- 
tioned in the succeeding chapters are only part of the work of psy- 
chiatry. In the field of morale we are inevitably led to consider not 
only the influence of the film but the actual technical details in the 
planning of films because these, whether they be for training purposes 
or for entertainment value, have a profound effect upon those who 



5 o THE SHAPING OF PSYCHIATRY BY WAR 

see them. So much depends upon the presentation of a particular 
subject. Radio presents an equally big study of which all too little has 
been made so far, though in the war considerable progress has been 
made towards helping with the wider problems of morale and welfare 
through the medium of broadcast programmes. Sociological tech- 
niques have been used considerably. These are not new, but perhaps 
more use has been made of them for purposes of planning than often 
happened before the war, save perhaps by certain commercial firms. 
Opinion surveys, social surveys and, indeed, social work as a whole 
have certainly made some advance. 

In considering the impact of war and its effect on psychiatry, it is 
worth while to remember how challenging to psychiatrists has been 
the fact that they are working in countries other than their own. I 
know little of the American work or of developments in Asia and 
Australasia, but British army psychiatrists have been breaking new 
ground in every part of Africa, in India and elsewhere. Here in most 
cases they have been dealing with native races and to some extent 
affecting the local conditions of civil practice and often, of course, it 
has not been so much that new advances have come about but that 
knowledge and procedures familiar to us have been introduced where 
none existed before. Modern treatment has been introduced, and 
much educational work is being done, as for example in India where 
many postgraduate training courses have been arranged, new hos- 
pitals have been erected that will serve after the war for the civil 
population, the standard of nursing has been raised and personnel 
trained where before there were none. Selection techniques have been 
introduced, and there are many entertaining and interesting stories of 
the special tests which have had to be devised for the selection of men 
in African tribes for training as tradesmen, and of the tests that have 
been developed for the multifold races of India. Officer selection pro- 
cedures have been breaking down the old ideas of nepotism and in- 
fluence in selecting likely material from the peoples of India, and 
these are foundation stones upon which psychiatry can build some- 
thing of almost incalculable social value in the future. 



THE FRONTIERS EXTEND 51 

We are talking a great deal about social medicine in these days. 
Psychiatry is largely social medicine and it is certainly true that social 
medicine is mainly psychiatry, and all its experiments and develop- 
ments must be coloured by a psychiatric approach. Just at the moment 
we have a greater need for good medical sociologists than for good 
clinicians, though we assuredly need both. The good clinician will 
have his maximum contribution to make to social medicine in a few 
years when he has grown into a more sociological approach to his task. 

The challenges of war bring us out of "our tents," our hospitals, 
laboratories and consulting rooms. Probably few of us ever accepted 
the overoptimistic statements of some of the politicians that we were 
members of nations whose health and constitution were Ai. We cer- 
tainly none of us suffer from that delusion now. We have seen so 
much of inadequate and unfit men and women that we are almost 
staggered at the prospect of the jobs that lie ahead of us, though in 
fact this outlook should be more stimulating than frightening. While 
it is true that war provides us with problems, peace will provide us 
with far more. As psychiatrists who have seen the extending frontiers 
we can say with all humility that we can use our discipline, shape our 
science and our art to make some greater contributions to the future. 



CHAPTER TWO 

OPPORTUNITIES EMERGE 



IT MUST already be clear that because they create so many vivid and 
difficult situations wars provide opportunity for psychiatrists more 
than for other physicians. The actual challenges of war are not new 
or different in their quality from the stresses of civilian life but they 
occur with greater intensity and at an increased tempo so that they 
appear to be quite different. We certainly find that we have uses for 
all our normal civilian skills and, what matters more, that we are 
forced to the development of new techniques. This happened in the 
1914-18 war and we have rediscovered it in all armies in this war. It 
certainly is important that we should maintain our interest and our 
zest for the postwar period. What will technically be called "peace" is 
not, in fact, likely to be very peaceful if by that one means that the 
tendency towards war will of itself disappear. The demands upon 
all scientific men will be great, and psychiatry will have its full meas- 
ure of problems demanding solution. We shall need a more and not 
a less aggressive and enterprising spirit in attacking the problems of 
peace. 

The army and the other fighting services form rather unique ex- 
perimental groups since they are complete communities, and it is 
possible to arrange experiments in a way that would be very difficult 
in civilian life. Consequently sociological and psychological aspects 
of the group can often be better studied within a service than any- 
where else. It is unfortunate that to date, whilst many papers mostly 
on clinical aspects of war psychiatry have been published by civilian 
physicians, few of those who are working within the services on the 
development of new procedures have had time to write any full and 
exact accounts of their work. There will be a harvest to be reaped 
at the end of hostilities and we must make sure that good use is 
made of it. 



OPPORTUNITIES EMERGE 53 

MANPOWER 

The basic need of an army is manpower, and in this war that word 
must also, for the first time, be taken to include woman power. No 
amount of equipment can make possible the winning of a war with- 
out the men to use it, and for its effective use they must be the right 
men. Before this war the strategists had often debated the question 
as to what size an army should be: was it important to have vast num- 
bers with less skill, or should an army be smaller but of a very high 
quality in intelligence and professional training? Probably the Ger- 
mans from their point of view showed a good deal of shrewdness 
when, faced by heavy restrictions on the size of their armed forces, 
they decided to utilize selection techniques to ensure that every single 
man in that force was of high quality, and consequently got the sort 
of personnel who later could be used as a framework on which to 
base the subterranean and illegal expansion of their forces. The 
allocation of manpower in a country at war is, of course, a question 
for high-level decisions and the policy in this war has been shaped 
and reshaped according to the pressing needs of the moment. 

In a country like Britain with a limited population and very heavy 
calls upon manpower for industry as well as three fighting services 
and a large civilian defence service it was obvious that the point 
would be reached before long where the quality of the men and 
women who were available must be taken into account in shaping 
higher policy. Armoured regiments cannot be manned by men of 
inferior physique or inadequate mentality, and elaborate radio-loca- 
tion plants are not usefully operated save by intelligent men or 
women. These issues which have emerged during the war have been 
sufficiently clear to ensure that should there have to be similar plan- 
ning in the future they are likely to be heeded and studied from the 
beginning. It is equally certain that in the reorganization and de- 
velopment of industry these concepts will be more fully appreciated 
for the future. Whilst it is clear that all men are equal in their pos- 
session of emotional needs, however much these may vary indi- 



54 THE SHAPING OF PSYCHIATRY BY WAR 

vidually, we are indeed forced to accept the fact that they are not 
identical in their capacity to learn and to acquire skills. 

A mere census of heads does not give us a measure of our potenti- 
alities, and we can go further and recognize that to maintain efficient 
output we must have a large proportion of our people doing the 
particular job that is within their competence. We have, in fact, very 
many of us come to accept the fact that the principles of vocational 
selection and guidance are essential in the interests of both the indi- 
vidual and the community, though we shall still have a great deal of 
patient work to put in before employers, politicians and others are 
convinced of this. 

The army has always recognized that it must have fit men. In the 
United States I believe your policy has always been that a man must 
be fit for anything or he is not fit to be in the army. In the British 
army, much as we should have liked to take that point of view we 
have never been able to, owing to our manpower position, and the 
principle of limited service has always been accepted. The standards 
of physical fitness have been adequately laid down and maintained, 
but as the last war showed and this war has emphasized, owing to a 
failure in our medical training there has been insufficient under- 
standing of what constitutes mental fitness for army life and for war. 
If men are badly selected then their training must suffer and without 
good training the value of your army is small. The dull man cannot 
be trained rapidly nor can he, in many cases, learn the many skills 
that modern warfare demands of him. The man with long-standing 
neurotic difficulties may perhaps get through his training satisfacto- 
rily, but when it comes to the real stuff of war, the fighting, he will 
fall by the wayside if he has not done so earlier. We have therefore 
had to emphasize far more than is ever necessary in civil life the 
intelligence and stability which armed service demands. Without 
such selection it would be impossible to maintain the health or the 
morale of a modern army at high level. 

There is a very valuable document familiar to many readers since 
it has been much quoted, the Report by the British War Office Com- 



OPPORTUNITIES EMERGE 55 

mittcc of Enquiry into Shell Shocf( which was published in 1922. This 
was the result of a lengthy and very comprehensive enquiry into 
every aspect of the neurosis situation which had arisen in the last 
war and makes surprisingly interesting and relevant reading even 
today. Three paragraphs may be quoted here: 

It is clear to us that during 1916 and 1917 the question of the "condi- 
tion of the nervous system'* of the recruit did not receive adequate con- 
sideration either in the instructions to recruiting medical officers by the 
military authorities or in the minds of the officers actually engaged in 
the medical examination of recruits, though recruits with gross nervous 
defects, e.g. having been certified insane, or with epilepsy, were rejected 
when these defects were ascertained. Generally, the evidence we have 
heard has convinced us that enough attention is not yet paid to the mental 
and psychological aspects of military service (page 166). 

During the first three years of the war, however, it is evident to us 
that the importance and complexities of this particular aspect of the re- 
cruiting problem were not grasped, nor did the procedure in force at 
successive stages of these years result in any real discrimination between 
those recruits who were, and those who were not, of normal nervous 
stability. As a result a great number of men who were ill-suited to stand 
the strain of military service, whether by temperament or their past or 
present condition of mental and nervous health, were admitted into the 
army; there is no doubt that such men contributed a very high proportion 
of the cases of hysteria and traumatic neurosis commonly called "shell 
shock." 

It seems probable to us that, had a more prolonged period of graduated 
training been possible, a certain percentage (probably not large) of such 
men could have been developed into efficient soldiers, certainly for the 
noncombatant arms, but it is extremely doubtful how far the necessary 
time and attention, which would have been required for this purpose, 
would have been worth while. Further, experience shows that once a man 
is accepted for service, it is in practice impossible to ensure that he will 
not be employed in the firing line; in periods of emergency, military 
exigencies override every other consideration. We are of the opinion that 
the army would have been better off without them (page 169). 



56 THE SHAPING OF PSYCHIATRY BY WAR 

The committee also said, on page 135, "all cases of mental dulness 
or deficiency should be sent home for invaliding." To some extent 
this situation of the last war has been repeated since 1939 though it 
has not been so marked. Too many dull men found their way round 
the Cape of Good Hope to the Middle East or to India and then had 
to be returned as invalids. A colonel of the Red army medical service 
when asked recently what happened to dullards in his army said, 
with the greatest confidence: "There is no place for any dull men in 
the modern army; we keep them out or if they get in, we send them 
back to industry at once." 

It was recorded in the last chapter that, for reasons which are not 
clear, the medical services of the army did not implement a scheme 
which was suggested to them in the early part of 1939 for the de- 
velopment of a selection procedure. This scheme was to come into 
operation straightaway in the militia, which was then being called 
up, with the idea that a satisfactory and improved imitation of the 
United States army work of the last war would be developed and 
be ready to put into operation by the time general recruitment, then 
almost inevitable, began. *In September, 1939, as an addition to the 
scattered half dozen regular officers with specialist experience, the 
only psychiatrists recruited for the British army were two consultants, 
one with the British Expeditionary Force in France, and one in Great 
Britain, so that the amount of psychiatric work or prophylactic 
activity that could be undertaken was strictly limited. As soon as 
extra psychiatrists were brought into the army early in 1940, they 
were inevitably faced with large numbers of unsuitable and inade- 
quate men and had to begin combing them out. Many had to be 
discharged as unfit for service, some could be better placed or more 
usefully employed in their own or other arms of the service. A variety 
of intelligence tests was brought into use by the different psychia- 
trists, each using those procedures with which he was most familiar, 
and at first the standard of clinical judgment necessarily varied some- 
what as among different men faced by the new problem of measuring 
men for the army. It was perhaps fortunate that there was this flood 



OPPORTUNITIES EMERGE 57 

of inadequate and dull men because it forced us to do something 
about selection, and all the early selection procedures had to be oper- 
ated by psychiatrists since there was no one else to do it. 

The Penrose-Raven Progressive Matrices test had just been 
published before the war. It was worked out as a test for defective 
children though it had been used on adult groups as well. Through 
the work of Hargreaves at the Royal Army Medical Corps Depot in 
Leeds the matrix test was brought into use as a group test and was 
standardized for the ordinary population group and has been, and 
still is, one of the main instruments for intelligence testing in the 
British army. It is a particularly useful test because it is nonverbal. 
It is so designed that it does demonstrate a man's ability to learn 
by experience and to argue by analogy. It is easy to give as a group 
test and easy to score. This was, in fact, pioneering work and I am 
reminded that so new and strange was this work to the army that 
all the original copies of the matrix test were paid for out of the 
psychiatrist's own pocket! From this at a very early stage a great 
deal of useful information was obtained. Experiments of squadding 
recruits in training by intelligence were very successful and although 
the method has never been universally adopted in the British army, 
the Canadian army, through its Brantford experiment, has demon- 
strated the value of this grading for training so that it is now adopted 
at all their training depots. 

This method of three-speed training where the above average, the 
average and the below average are grouped separately is eminently 
common sense. The three groups need varying times in which to 
reach the same point of competence and while this adds slightly to 
the administrative work of posting men on to their next stage of 
training it ensures better training, it saves the tempers of instructors 
and it adds to the good morale of the actual groups of trainees who 
are working with men rather like themselves. So many dull men 
break down during training because of their feelings of inferiority 
and anxiety engendered by their slowness compared to their fellows 
that it seems obvious that this principle in training is susceptible of 



58 THE SHAPING OF PSYCHIATRY BY WAR 

much wider application within the armed forces and also in training 
for industry. There is, of course, nothing new in it, for schools have 
for many years adopted this principle, but in the training of adults 
it seems to have been overlooked. 

The early experiments in group testing having proved successful 
it became possible to apply them to complete formations of men, and 
many such procedures were undertaken by psychiatrists in the early 
days of the war. Out of this work arose many problems of the dis- 
posal of those who were found to be below standard and the de- 
velopment began of suitable instructions for the handling and dis- 
posal of the various types of men with psychiatric conditions in the 
army. None of them had been clearly formulated before that time. 

It is interesting to record that somewhat later a parallel experiment 
was tried, not under medical auspices, of civilian psychologists work- 
ing in group intelligence testing. This experiment made it quite clear 
that selection on any adequate scale could not be effective in the 
army unless it was run by personnel already in the army, knowing 
and understanding the needs of the situation. Therefore, as the 
situation developed, since the medical services were still unwilling 
to concede that this was a part of their function, a Directorate for the 
Selection of Personnel was set up under the adjutant general, where 
it still is. The Royal Navy got its selection service going a few weeks 
ahead of that in the army and has progressed along very similar lines. 
The RAF was somewhat later in starting selection procedure for its 
ground staff. The selection of air crews, a different and much more 
elaborate procedure, had, of course, been operating since the begin- 
ning of the war. 

This is not the place to present details of the battery of tests which 
are in use for selection purposes in the army. That is the responsibility 
of the psychologists, and there is, in any case, a very considerable 
resemblance between the tests used for intelligence and ability in all 
the different armies. There are, however, one or two points of interest 
to record. For selection to be effective it is essential to know the nature 



OPPORTUNITIES EMERGE 59 

and requirements of the particular job and the number of men 
required for each special operation within any particular unit. Conse- 
quently, one of the first jobs undertaken by the Directorate for the 
Selection of Personnel was a job analysis for every unit of the army. 
This provided a basis for the posting of men to any particular unit. 
It is clear, for example, that while most units can employ a certain 
number of men whose intelligence comes below the tenth percentile, 
it is risky to post men below the fiftieth percentile to most specialist 
duties. Ideally, at any rate, officers and a majority of the NCO's should 
come above the seventieth percentile. 

It is clear that posting on the basis of intelligence and job analysis 
must immediately do something to add to efficiency. Allowing for 
the fact that group tests are not infallible and that the individual 
cases will need to be specially dealt with, it is demonstrated that a 
sieve such as is provided by a battery of tests does do something 
towards placing square pegs in square holes. Selection in the army 
cannot provide for every man the job he would like, nor can it put 
him into his own job which may not even exist within the army's 
structure. The main purpose of the army is fighting, and that is not 
a civilian trade. An important fact from the army's point of view is 
that the 10 to 20 per cent of potential problem men, the dull and the 
unstable, are referred at the intake selection procedure to the psychia- 
trist so that their placing is much more individually tackled and 
better use is made of them. Selection in the British army, which began 
on this organized basis, was applied to units that were forming or 
re-forming for special jobs and is now applied to the whole recruit 
intake coming into a general service corps for basic training. After 
being equipped and having their preliminary training they are posted, 
on the findings of the selection procedure, to the particular corps 
or arm of the service to which they are best suited. The follow-up 
and validation of these techniques have gone on steadily. Innumer- 
able variations of the procedure have been devised for special tasks 
and for special groups of men and women, and in London, as in 



60 THE SHAPING OF PSYCHIATRY BY WAR 

Washington and Ottawa, an enormous amoifnt of material resulting 
from these scientific tests and control experiments has been accumu- 
lated for the future. 

To this brief sketch of the introduction of selection methods in the 
army there are a few points that can be added. In the absence of fully 
trained psychologists with experience in psychometric methods, the 
British army has made use of regimental officers and noncommis- 
sioned officers who have, in addition to their knowledge of the army, 
some scientific training and occasionally some specific psychological 
training. As personnel selection officers and sergeant testers they have 
done a first-class job and one hopes that after the war, with some 
further specialized training, many of them will continue in this 
branch of work which interests us as psychiatrists so intimately. The 
morale value of selection has been very marked. The old grumble 
that men were badly utilized in the army and misplaced has almost 
disappeared even though the recruit cannot always get into the type 
of unit or sort of work he wishes. He does feel an effort has been 
made; people treat him as an individual and not as a cipher and he 
appreciates that and reacts to it just as the working people in the 
Western Electric Hawthorne factory reacted to the personnel man- 
agement procedures there employed. It is, of course, not only the 
fact that some objective basis for a man's employment is sought 
through the use of the battery of tests. The effect of the personnel 
selection officer's interview is even greater. These regimental officers, 
after special training, become very adept at interviewing. The survey 
of a man's past history, his education, sports, work, hobbies, etc., 
provides the basis for allocation to appropriate training and this gives 
the recruit his confidence. The personnel selection officer's interviews 
further provide a screen for the neurotic, unstable or difficult men, 
who would not be spotted by intelligence tests but who should be 
referred for psychiatric survey. 

One of the most difficult problems of the psychologists has been 
to produce an adequate validation of their work. It has been easy to 
prove that training has benefited by having men better selected; it 



OPPORTUNITIES EMERGE 61 

has, for instance, been clear that tradesmen were chosen better by 
these methods than by any others. But the final proof, that of battle 
worthiness, is a much harder thing to demonstrate. There have been 
a few instances of formations in which selection has been very thor- 
oughly carried out: men had been removed when they were found 
to be inefficient, and those who were doubtful on grounds of stability 
or intelligence had been referred to the psychiatrists and disposed of. 
These formations have put up unusually good performances in battle; 
the incidence of battle neurosis has been low and the general quality 
and morale of the units have been notably high. 

Unfortunately, as related above, the beginning of selection was 
delayed in this war and many horses were out of the stable before the 
door was shut. It is sad but true that no force has yet gone overseas 
from Great Britain every man of which has gone through selection 
procedures, and so one of the most important means of demonstrat- 
ing the value of selection has been missing. 

In another way we have missed our opportunity, though not 
through lack of eflort. The three services in Great Britain, Royal 
Navy, Army and Royal Air Force, are separate in their recruitment 
and in their internal selection procedures. In consequence some wast- 
age and misplacement of men are inevitable since certain men with 
particular qualities who cannot easily be employed in one service 
might be more efficiently employed in one of the other services. With 
that efficiency for which America is so noted, you have, in the United 
States and Canada, avoided this by having a large degree of unified 
selection at your induction and reception centres. Perhaps the Ca- 
nadian reception centres stand out as the most interesting foretaste of 
what might be done in civil life. Here the medical investigations are 
all done on the conveyor-belt system, as in the United States, with 
the psychiatrist included in the team and the personnel selection 
officers (army examiners) at the end of the line. Since each of these 
reception depots serves a military district of Canada and all pre- 
liminary posting is done within that district the numbers involved 
are not so great, and all posting is more individual and, in fact, is 



62 THE SHAPING OF PSYCHIATRY BY WAR 

done by hand rather than by mechanical sorting methods. Conse- 
quently, there is a better chance for the man's successful posting 
after adequate consultation among all the specialists concerned. 
Furthermore, should he break down during training or prove un- 
suitable he comes back to the same team of medical men and army 
examiners, who thus see their own mistakes. If selection is to be 
introduced on any wide scale in civilian life this is perhaps the model 
for it since it could be so well carried out in a circumscribed but not 
too small industrial area. Many civil trades and types of occupation 
will be represented and the available workers could with more cer- 
tainty be placed in the particular work that suited them. It would 
indeed lead to chaos if selection methods were only carried out by 
the larger and wealthier firms who would thus skim ofT the cream 
of the workers thereby tending to put intelligent men and women 
into their unskilled jobs and to leave other quite unsuitable per- 
sonnel to undertake skilled work in smaller concerns. Only an area 
distribution with an adequate and well-controlled selection service 
utilizing the results of proper job analyses can avoid this. 

Selection has been demonstrated clearly to be an essential part of 
social medicine, one of the most important available prophylactic 
measures against industrial or occupational stress, and it is important 
to emphasize this aspect. There still is a feeling abroad that any 
method of selection is a mechanism by which the wicked capitalist 
aims to get more work out of the worker, and that argument dies 
hard. The important thing adequately demonstrated in the service 
is that selection gives to the individual a job that "fits," greater happi- 
ness and better health. 

SELECTION OF OFFICERS 

The methods of group testing coupled with interviews used for 
the posting of men within the army have many modifications de- 
signed for the better selection of specialist groups, such as those who 
have to operate particularly complicated instruments, those who 



OPPORTUNITIES EMERGE 63 

need particular mechanical ability and so forth. Except for the 10 
to 20 per cent of men who are referred for various reasons for psychiat- 
ric examination little emphasis is placed in these procedures on the 
finer shades of character and personality. When the selection of men 
to be trained as officers is considered it is clear, however, that these 
are the sort of points that matter very much and an interesting de- 
velopment has occurred in the British army in the methods of officer 
selection. 

It is certain that any army must have good officers: if it has not got 
them it can never function as it should. The capacity for leadership, 
the ability, character and insight of the officer are of paramount im- 
portance for the happiness and welfare as well as for the efficiency 
of the men he commands. Far too many men have broken down 
because of having indifferent officers. Too many units have failed in 
their task at some vital moment because they were inadequately led 
and insufficiently knit together as a team. In peacetime the army 
chose its officers with some care; those who selected them knew the 
types of young men coming up through certain schools; they knew 
and understood their background and were reasonably well able to 
assess their quality. A long and careful training and adequate super- 
vision produced a very fine type of officer who grew into his job 
and deserved all the praise he got for the handling of his team. There 
were, of course, exceptions to this rule. In the last war when the need 
for officers became marked there were plenty of men who could be 
judged on the experience of their qualities in actual battle, and men 
were sent for training as officers because they had actively proved 
themselves in their positions as noncommissioned officers and were 
known to possess the necessary qualities. The Royal Navy still has 
the opportunity of seeing its young men at sea on active service for 
a time before it considers them as candidates for commissions. The 
British army had not got adequate opportunity for this kind of 
experience in the early days of the war. There were, in 1941, con- 
siderable heart searchings about the high rejection rate from officer 
cadet training units, and, because unsuitable men were being sent 



64 THE SHAPING OF PSYCHIATRY BY WAR 

up and then having to be rejected, there was a serious wastage in 
training time and the morale of these OCTU's was obviously affected 
by the large proportion of failures. What matters more perhaps is 
that a good NCO who had in fact reached his ceiling, but was sent 
up to OCTU, failed there and went back to his unit a disgruntled 
man who would no longer be a good NCO. Candidates were recom- 
mended by their commanding officers but were selected at the board 
by a single interview which has with ribaldry been called the "magic 
eye technique"! Since the supply of young men from the universities 
and public schools was drying up, the interviewing officers sometimes 
found themselves rather at sea since for purposes of rapid assessment 
they understood too little the background and outlook of many of 
the candidates whose civil life experience had been so completely 
different from anything of which they had previous knowledge. A 
candidate who could "sell" himself well might get past, though un- 
suitable; the diffident candidate, though potentially admirable, might 
be failed. 

At this stage of the war army psychiatrists had accumulated con- 
siderable knowledge of the army and its personnel problems. 
Amongst other things they were constantly brought up against the 
fact that psychiatric factors were often responsible for producing 
inefficiency in officers; the psychiatric breakdown rate among officers 
was high. A considerable number of officers had been brought back 
from the reserve but were really unfit. Some of them had even been 
in receipt of disability pensions for neurosis since the last war. Many 
had clearly been inefficient on psychiatric grounds for quite a long 
time before they were sent for a psychiatric interview. Equally, quite 
a number of men newly commissioned from the ranks had a history 
of psychopathy which should have excluded them. It was evident that 
a neurotic breakdown had often occurred because the man was 
unable to carry the extra responsibility that came with his increase 
in rank, while his shortcomings in ability and personality might 
still have been compatible with efficient service in the ranks. It is 
interesting to note that the effect of increased responsibility has al- 



OPPORTUNITIES EMERGE 65 

ways been recognized in the army, and many years ago peptic ulcer 
was commonly spoken of as "sergeants' disease." 

It is clear, therefore, that the mental health of the potential officer 
should have as much attention given to it as his physical health, al- 
though this has never been attempted heretofore. Experiments were 
carried out in which all candidates were examined in great detail 
by medical specialists to see if the standard physical examinations, 
through which the men had passed before they were sent up as 
candidates, were adequate. It seemed that they were and that the 
main emphasis was, therefore, to be put on the psychiatric aspect of 
the problem. With the encouragement of the adjutant general various 
experiments were started to discover possible techniques for the 
rapid selection of large numbers of candidates. Two psychiatrists, 
Wittkowcr } and Rodger, did most of this preliminary work making 
careful studies first of a group of about fifty officers attending a com- 
pany commander's school. This was a useful group because reputa- 
tional gradings were available on all of these officers, who had been 
commissioned and had held responsible jobs for some time, while 
furthermore the commanding officer and those in charge of the 
training groups in the school knew their men very intimately and 
provided the best possible means for comparison and checking with 
the experimental findings. 

In this first experiment an assessment of officer quality was made 
on the basis of a group intelligence test, a short questionnaire com- 
pleted by the officer and a psychiatric interview which lasted on the 
average for about an hour. Some effort was made to reproduce and 
try out what was known of the German army methods of officer 
selection. To reveal temperamental and personality factors, laboratory 
tests were provided. One stress test was by the use of a "chest ex- 
pander" in which an increasing electric current came through as the 
candidate made his maximum pull on the strong springs. 

The results of these experiments were very encouraging since there 
was agreement in 80 per cent of the cases between the psychiatric 

1 Not at that time in the army; working on a Halley Stewart research grant. 



66 THE SHAPING OF PSYCHIATRY BY WAR 

opinions and those of the staff of the school. A second group of officers 
who were studied in the same way gave even better results, owing 
probably to the mutual education of the commanding officer and the 
psychiatrists in the significance of the personality features relevant 
to officer quality. The agreement between the two reports rose to 90 
per cent. This experiment was instructive with regard to the number 
of psychiatric symptoms displayed by this supposedly normal sample. 
In some cases where a clearly defined neurosis existed the psychiatrist 
could predict the outcome with a high degree of certainty; in other 
cases where minor phobic disturbances and personality deviations 
were found they turned out to be of less value as prognostic indices. 
In these latter cases it seemed that an estimate of officer quality could 
be reached by weighing the psychiatric evidence along with the 
observations made by others. The results obtained from the laboratory 
tests were always rather doubtful; it was difficult to know just what 
was being tested. They might reveal in certain cases the presence of 
anxiety but they gave no indication of the psychological status of this 
anxiety, whether it was from a deep-seated disturbance or from 
something very superficial. They were eventually, therefore, com- 
pletely given up. 

These original experiments, the data of which will some day be 
published, were so successful that it was decided by the authorities 
to set up the first experimental War Office selection board, from 
which grew the present scheme of boards in every part of the country 
and in the overseas forces, through which all candidates pass. The 
staff of each board consists of an experienced regular officer as presi- 
dent, a deputy president, three military testing officers who are line 
officers of some experience, one or two psychiatrists and a psycholo- 
gist, and in most cases sergeant testers who act as psychological 
assistants. Here therefore was a team collected for the first time to 
carry out an assessment of the whole man and his suitability for 
particular responsibilities within the army. 

It was interesting that at the beginning of this organization it was 
thought by some of the senior officers concerned that the original 



OPPORTUNITIES EMERGE 67 

work had been so successful that the whole answer could be given 
by a psychiatric interview added to the results of intelligence tests. 
In fact the addition of these other members of the team was said at 
that time to be largely cover for the psychiatrist and from that angle 
it certainly was wise that in the army there should be other non- 
technical members of the selection team. From very early days it 
became obvious that they were not just there for the sake of re- 
spectability but that they had an extremely valuable function to play, 
and that the three lines of approach to the candidates, when fused, 
were likely to produce the fairest and best ultimate result. There has 
always been an objection in the courts to trial by doctor and it is 
quite right that that should be so. Equally, in selection, the task of the 
doctor and the psychiatrist is to advise on physical and mental fitness, 
but the final word and assessment should be given by a man ex- 
perienced in the particular job for which the candidate is being 
selected, in this case a senior army officer. That there would be ob- 
jections raised to the psychiatric contribution to this team was clear 
from the amusing Story which we heard at this time. A certain very 
senior regular officer who was of the greatest help in the foundation 
of these special boards had, before the war, the distinction of being 
the only serving British officer who had seen the German army officer 
selection work in progress. On his return to this country he had 
pressed the authorities to start some similar work in the British army, 
but the suggestion was turned down and he was told, "X you're the 
bloody Freud of the British army!" We have not, of course, entirely 
escaped from the criticism of the less informed who have sometimes 
assumed that we were carrying out a thorough psychoanalysis of 
every candidate. 

The procedure of the War Office Selection Board which the adju- 
tant general approved was that all the candidates recommended by 
their commanding officers should come up for either two or three 
days to the board, where they lived in a hostel or mess in which they 
had many of the small comforts of an officer's mess. On the first day, 
after a welcoming and explanatory address by the president, they 



68 THE SHAPING OF PSYCHIATRY BY WAR 

went through group intelligence tests and projection tests, which 
will be referred to later. These provided at the very beginning ma- 
terial for the psychologist or sergeant testers to work upon. Next day 
their programme was divided between outdoor and indoor tests, 
situations of varying kinds being provided for them. Tests of mili- 
tary efficiency were clearly out of place since the experience of some 
of the men varied a great deal; they might have been in the pay 
corps or the medical corps and have little experience of weapons and 
tactics. Consequently the problems given to them were designed to 
demand common sense rather than military skill. Assault courses of 
varying difficulty were tried but for the most part the original plan 
was to provide situations that would show what men could do indi- 
vidually and in groups so as to give the fullest opportunity of assessing 
a man's assets and liabilities with respect to his effectiveness as a leader 
of a group, dealing with concrete practical situations. Lectures given 
on various topics as though to a squad of men gave insight into a 
man's personal attitudes even more than his capability of holding the 
men's interest or getting some difficult point across to them. 

The military testing officers who were responsible for these activi- 
ties were also living and messing with the men. Indeed the whole 
professional stafl of the board mixed with the men at meals and in 
the anteroom so that from the beginning, though strenuous, the whole 
procedure was on a very friendly basis. During the period at the 
board each man had an interview with the president or later, when 
the numbers increased, with the deputy president and an interview 
with the psychiatrist. On the last morning when the men were just 
going ofif, the final board conference was held at which the decision 
on the men's suitability was made. The president would ask for the 
rating of the psychiatrist, the psychologist and the military testing offi- 
cer in turn and give his own rating. If they all agreed then that was the 
conclusion of the board; if they difTered materially then each re- 
sponsible officer read his report and after a discussion a final rating 
was given which was the conclusion of the board. In large measure 
this procedure has persisted in all the various boards which have 



OPPORTUNITIES EMERGE 69 

been set up. A good deal of latitude was given to individual boards 
to devise their own testing procedures, but with the increase in knowl- 
edge and the expert validation of various tests their form has altered 
and certain well-proven procedures are universal at the boards. 

The difficult question of what was being sought for in the candidate 
to justify his acceptance has given rise to a great amount of discussion. 
An initial tendency to test for certain qualities was soon replaced by 
broader conceptions. There is probably no single quality that is com- 
mon to all successful officers, and the best approach therefore de- 
veloped along the lines of securing methods which would enable a 
picture of the person as a whole to be filled in, judgments being 
based on how well the picture matched the various roles which the 
officer has to fill. The two main fields of the personality which had to 
be investigated were (i) that covering his resourcefulness and adapta- 
bility or his competence, and (2) that covering the quality of his 
contact with others. The former is as a rule easier to reveal than the 
latter, but Bion's "leaderless group" principle marked a notable ad- 
vance in psychological methods of investigating interpersonal rela- 
tions. The basic idea underlying the method is that when a group 
of candidates are presented with a problem that they have to solve 
as a group, i.e. no leader is appointed by the testing officer nor is any 
help given, then a situation arises that reproduces the fundamental 
conflict between the individual and society. At the board, the indi- 
vidual is motivated by a desire to do well for himself personally, but 
by placing him in a situation where he can only operate through the 
medium of others, his spontaneous attitudes towards co-operation 
are revealed. The self-centred man either remains aloof or exploits 
the group by a dominant attitude in order to show himself off, 
whereas the man with good contact identifies himself with the pur- 
pose of the group, namely to achieve a co-operative solution to the set 
problem. The method can be applied in various types of tests and 
has been most often used in carrying out a discussion and in various 
practical tasks and games. 

The situation of course really becomes a social projection test, and 



7 o THE SHAPING OF PSYCHIATRY BY WAR 

the roles which the various members of the group choose for them- 
selves provide a great deal of material evidence about the person- 
alities. Inevitably certain individuals appear more prominently than 
others and the acceptance of these "leaders' 1 by the others can be 
observed. If they are mere "thrusters" without real competence they 
are soon deposed when the group discovers that their plans are quite 
ineffective; and even if they should be competent the attitudes of the 
others often reveals whether or not they are sensed as self-seekers 
rather than possessors of real team spirit. From the nature of the set 
problem, e.g. a discussion on a general topic or a practical task such 
as bridging some obstacle with material provided, much is learned 
about the general outlook or resourcefulness and competence of the 
individuals, but the important aspect under observation is how he 
reacts to the psychological problem of balancing his desires to show 
off as an individual against the need to be a member of a team. 

This method has been found to be most effective when observed 
by two or three board members, usually the president, the military 
testing officer, and the psychiatrist or psychologist. Naturally those 
candidates who are most prominent tend to be most easily assessed 
but the method is not thought of as a test of leadership. Leadership 
is not a single quality possessed by some and not by others but is 
a way of describing the effectiveness of an individual in a specific 
role within a specific group united for a particular purpose. The 
method gives data on all the candidates in the group although the 
observers often find at the end of a leaderless group test that they 
have been set problems rather than that they have got answers 
about a particular candidate. This raising of problems is freely 
discussed by the observer group who are then in a position to de- 
cide what further testing methods will be most useful, e.g. whether 
the candidate should be carefully observed when put in charge by 
the testing officer or whether he should be interviewed at length by 
the psychiatrist. 

At the end of the board program a useful check on the inter- 
personal relations of the candidate is obtained by asking each to 



OPPORTUNITIES EMERGE 71 

write on a strip of paper the candidates he values most highly for 
certain situations, e.g. a social evening, getting out of a tight corner, 
platoon leader, etc. This sociometric test is often highly revealing. 

The psychiatrist is technically the best trained member of the 
board, for there have been few fully trained psychologists available, 
and so he has played a considerable part in the designing of out- 
door tests and indeed of the whole technical procedure of each 
board. The opinions and judgment of the nontechnical members 
of the team have grown increasingly valuable and the situational 
tests have themselves provided material for psychiatric judgments, 
which may even be as valuable as the psychiatric interview itself. 

From the beginning the work of the psychologists and psychia- 
trists was well integrated. The first psychologist of the experimental 
board (Sutherland) was, in fact, a psychiatrist as well as a general 
psychologist and later, when the present senior psychologist (Trist) 
appeared on the scene, the same close co-operation was kept up. 
The experimental board has continued and has become the Re- 
search and Training Centre and the team of psychiatrists and psy- 
chologists there has been fused into one of the best co-operative re- 
search teams that could be imagined, talking the same language 
and pursuing a common end by the use of their varying experience 
and training. The validation of tests, the devising of new pro- 
cedures and the standardization for various purposes of the selection 
techniques have made an extremely valuable contribution and it is 
hoped that much of the technical results of their work will begin to 
be published quite soon for the benefit of those who are interested 
in this type of specialized selection. 

At the beginning of the work it was realized that intelligence tests 
were certainly necessary and a battery of these was devised and officer 
intelligence ratings agreed upon so that no candidate should go on 
to the officer cadet training unit whose intelligence was lower than 
the fiftieth percentile, i.e. an officer must have an intelligence above 
the average of the men he is to command. In fact, of course, the 
intelligence of the majority is a good deal higher than this. Intelli- 



72 THE SHAPING OF PSYCHIATRY BY WAR 

gencc by itself proved to have a fairly low correlation with the final 
acceptance of the board after full observation of the candidates, but 
the value of the intelligence rating was from the beginning quite 
clear because it helped all the members of the board in arriving at 
their assessment of the individual. Twenty per cent of candidates 
with the highest intelligence rating were failed upon personality 
grounds as might be expected and it was early realized that in select- 
ing men for commissioned rank the personality factor was the major 
consideration, provided that the candidate had adequate intelligence. 
In order to assess the personality there was, of course, the psychiatric 
interview and this was known to be a sound approach, but at the 
same time it was hoped to find other tests that would supplement 
the interview and reveal personality factors. The laboratory apparatus 
referred to above was finally given up and many other forms of test 
were tried. Group Rorschach tests were used but had to be abandoned 
because of the time needed and difficulty in administration and inter- 
pretation. Finally, three group projection tests were developed which 
proved so valuable that they have been retained throughout with 
certain modifications: an adaptation of Murray's Harvard Thematic 
Apperception test, an adaptation by Sutherland of the Word Associa- 
tion test, and a Self-Description in which the candidate described 
himself in two or three minutes as his best friend and as his worst 
enemy would describe him. These, together with questionnaires, one 
dealing with his experience and the other a medical questionnaire 
bringing out health and psychosomatic factors, with the intelligence 
tests, combine to form the battery through which every candidate 
passes. From the whole battery of written tests, the psychologist and 
his assistants construct "personality pointers" a term deliberately 
introduced to make clear the limited scientific status of the inferences 
made about the person. The "pointers" can be used as a basis for 
screening for psychiatric interview and also as psychodiagnostic aids 
in the conduct of the interview. 

Because of the time factor the psychiatric interview proved to be 
the bottleneck of the procedure and so it became increasingly im- 



OPPORTUNITIES EMERGE 73 

portant that these personality pointers proved to be of great value 
and accuracy. They pick out the men in whom there is some evidence 
of instability or peculiarity of personality who must therefore be 
interviewed psychiatrically. The procedure provided a method by 
which the group could be "topped and tailed." Some men who were 
clearly of low intelligence would be hardly worth a lengthy inter- 
view, those whose personality pointers and intelligence were both 
beyond question were almost sure to be passed and the psychiatrist 
was equally sure to find nothing wrong. Therefore psychiatric time 
should, in this way,. be saved and the partially trained psychological 
personnel could be utilized in the giving and first scrutiny of this 
test material. Should this same plan be followed, there may be in 
the ideal setup of peacetime, fully trained psychological personnel 
available and so little pressure on time that a psychiatrist can give 
interviews as long as he feels necessary to every candidate. Under the 
pressure of army life, however, the sergeant testers have functioned in 
relation to the psychiatrists as senior medical students do in relation 
to the physician in charge of a hospital ward, or the technician in 
the pathological laboratory. 

The psychiatrist at first saw every candidate and while this was 
possible there were great advantages in it. The candidates, almost 
without exception, approved highly of this and found the psychiatric 
interview interesting and convincing. When, partly for reasons of 
shortage of psychiatrists and partly for political reasons, he saw 
only a proportion of the candidates, those whom by their personality 
pointers it was thought should be seen, or those whom the president 
or military testing officer felt were somewhat doubtful, candidates 
began to make some criticism of the psychiatric role. This was 
inevitable because if only certain of the men see the psychiatrist there 
is an implication that some are a little peculiar and therefore the 
psychiatrist takes on a slightly more sinister colour than he has when 
he is just a member of the technical team. It is certainly desirable that 
where a psychiatrist is used in this procedure he should see every- 
body even though in some cases it be for a very brief interview. The 



74 THE SHAPING OF PSYCHIATRY BY WAR 

psychiatrist in each of these boards has been the senior technical 
member because in Great Britain we have had this difficulty in pro- 
ducing sufficient psychologists with adequate training and because 
the main problem has been that of personality and character assess- 
ment. 

The psychiatric interview has always been regarded as a medical 
matter and consequently as something confidential. Candidates, 
therefore, have felt free to discuss whatever they wished, knowing 
that personal details would not be passed on to the board, though 
understanding, of course, that a general assessment of their suitability 
would be given by the psychiatrist. A very typical remark by an 
intelligent officer, who was up at one of the boards choosing candi- 
dates for commissions for the regular army, was made to the psychia- 
trist. He said, "I think this is the most important part of this board 
procedure; you know more about me now than anyone has known 
in my life and I should feel that your judgment of my suitability 
was worth more than anyone else's opinion/' By and large that is 
true and the psychiatric contribution to this type of selection is of 
the greatest importance. A comparatively small number of candidates 
are turned down on grounds of overt psychiatric disability, but 
mental unfitness of various kinds, especially for particularly difficult 
roles, is quite often revealed. The most important contribution is 
through the assessment of the difficulties that a man is likely to de- 
velop, which might become liabilities under stress or lead to some 
serious behaviour disorder which would affect the unit under his 
command. 

The psychiatric interview in officer selection work differs, of course, 
from that with a patient in a consulting room. The candidate here 
must take the lead; one cannot pose all the questions that would be 
obvious in a consulting room and in this particular setting it has been 
found wise to avoid any direct questions about sexual matters or 
similar topics which might be resented by candidates. Nevertheless, 
the facts emerge and the psychiatrist who has a psychodynamic out- 
look finds that his interview brings out without much difficulty nearly 



OPPORTUNITIES EMERGE 75 

all the points that should be faced. It matters to the candidates 
whether they are chosen to be trained for a commission and most of 
them are entirely co-operative in submitting their personality for 
scientific scrutiny. They feel it is not only thorough but fair and, in 
fact, the psychiatrist is responsible more often for strengthening the 
claims of a candidate than for recommending his rejection. That the 
board is concerned with a man's personality and mental quality is 
a demonstration to the candidate that the army is no longer unduly 
biased by questions of social and educational status. The board pro- 
cedure is regarded by candidates as being essentially fair and demo- 
cratic and as something to be welcomed whether they are accepted 
or rejected. 

This sense of the fairness of selection procedure has been very 
satisfactory and has made some contribution to the good morale of 
the army. Nepotism has certainly diminished and the sense that men 
are chosen for their worth and not for their antecedents or their 
social connections has been all to the good. In fact, although the 
proportion of candidates accepted under the new board methods 
was almost exactly the same as obtained under the old interview 
method, and the two methods were both operative for a period in 
the army so that comparable groups were available, the new method 
has been markedly successful. Judging by the gradings at officer 
candidate training units three above-average cadets were discovered 
by the new method for two who were discovered by the old interview 
assessment; in other words, of every three potential above-average 
cadets who appeared before the old board, one was rejected. A serious 
loss to the army and an injustice to the individuals concerned have 
therefore been avoided. The follow-up of this work has been very 
fully organized. It has been an extremely difficult task especially to 
get adequate ratings on officers who have actually been through battle 
overseas. There is, however, no question from the follow-ups so far 
completed (Bowlby) that the procedure has succeeded in improving 
officer quality, that it appears to have diminished the number of psy- 
chiatric breakdowns in officers and that it has certainly avoided the 



76 THE SHAPING OF PSYCHIATRY BY WAR 

discontent and difficulties resulting from failure and returning men to 
their unit during their training. The full and detailed statistical find- 
ings of the follow-up will be available at the end of the war. 

Many of us have applied the old saying that "there are no bad 
soldiers, only bad officers" to spheres of life quite different from the 
army. We have had visions of how different things might be if our 
legislators were chosen for character, personality and intelligence 
rather than for political party; if schoolmasters, doctors and lawyers 
were chosen with personalities and abilities suitable for th^ir tasks; 
and, indeed, new vistas open out nowadays since it has been demon- 
strated that an adequate and acceptable technique has been de- 
vised. The general principles underlying the War Office Selection 
Board procedure seem to be sound and they should be capable of 
modification to suit many different situations. They have, in fact, 
already been modified, first of all for the selection of women officers. 
Here there were difficult problems to be faced since the tasks and 
quality of an officer in the women's services differ materially from 
those of men officers in a combatant army. New standards and new 
test situations were devised after an investigation or analysis of a 
woman officer's job had been made, and here again there seems to 
have been a considerable degree of success in selection. Officers for 
the civil defence organization in Great Britain have been selected by 
the army boards, and the army has now assisted the civil defence to 
set up its own board on similar lines. Various special groups of candi- 
dates for special arms and for the other services have been put through 
the same procedure successfully and experiments have been made 
with the civil service. Some recent modifications have been intro- 
duced for the selection of adolescents, senior boys from school who 
are being chosen for short university courses prior to going into the 
army. Here special difficulties arose because the whole question of 
maturation had to be assessed and educational attainments had to be 
considered as well. The psychiatrist appears as the doctor on these 
boards, making a medical check up, since it would hardly be reason- 
able to expect the average adolescent to appreciate the relevance of 
the psychiatrist in the board assessment, and the individual psychia- 



OPPORTUNITIES EMERGE 77 

trie interview is replaced by a group discussion conducted by the 
psychiatrist. This selection technique has also been extended to army 
officers who, for various reasons, are badly placed or unsatisfactory, 
and here again it has shown itself to provide a very useful team for 
the assessment of their qualities and suitability for further service 
or the reverse. 

It is of some importance to remember in thinking of selection, 
whether it be of men in large groups or of specialists where the pro- 
cedure can be in greater detail, that in the army one is selected for 
specific martial roles and that it would be disastrous if gradings or 
rejections made for these purposes were to cling in any way to the 
future life and reputation of the men so graded. The man in the 
lowest selection group, the SG 5, may have a limited value to the 
army, but he may be a first-class man in his particular niche in civil 
life. The officer who lacks the kind of qualities to make him a leader 
of fighting men may be one of the great men in his own subject, for 
it is doubtful whether many of the leaders in our cultural life would 
emerge as obvious infantry soldiers or tank commanders. We must 
never make the mistake of confusing the results of selection for some 
specific task with the assessment of a man's potential contribution 
to life as a whole. A man's failure to fit into some particular niche 
should in no way upset our respect for him as a personality. 

THE PSYCHIATRIC CONTRIBUTION TO TRAINING 

As psychiatrists most of us have been interested in educational 
approaches and in theories of learning and the organization of schools. 
For many of us that has been intimately bound up with part of our 
professional work. Comparatively few men in psychiatry have, how- 
ever, had much to do with adult education or the problems that 
arise in industry in the training and equipping of men and women 
for specific jobs. We have certainly not been able to do all that we 
might or all that we should do in this field in the army, and there 
still remains a very considerable number of problems on which we 
could throw some light if we had the personnel and the time available 



78 THE SHAPING OF PSYCHIATRY BY WAR 

to undertake more work. Earlier, I referred to the training of men 
of varying intelligence at different rates and in different groups and 
to the success of the Canadian experiment. Canada has taught us 
many things and in the teaching of illiterates it has provided another 
object lesson. At the educational centre at North Bay there has been 
as clear a demonstration as anyone could wish for that good modern 
educational methods coupled with good welfare and high morale 
can produce the most startlingly good results in the education of 
men who are illiterate primarily through lack of opportunity rather 
than through innate dulness. The teaching of illiterates in our army, 
which has had a good deal of experience, is not always so satisfactory. 
There is a temptation in many units to try to teach men of very low 
intelligence to read and the optimistic and enthusiastic education 
sergeant wko instructs them is always convinced that there is marked 
improvement in his pupils. From the army's point of view it would 
be of little value even if the defective man did learn to read, for his 
reading would never be sufficiently quick or sufficiently certain to be 
of much value in the carrying out of his job as a soldier. There is 
something to be said, of course, for his learning to read and write, 
however laboriously, for the sake of family and social contacts. It is 
very clearly demonstrated, however, that for effective work with 
illiterates it is necessary to select the men carefully, picking out those 
with a reasonable intelligence and having done that, it is worth while 
to provide first-class teachers and first-class equipment to produce the 
right atmosphere and enthusiasm in the students and then you get 
rapid results. 

The widespread nature of illiteracy is a point upon which there 
are no very accurate figures but the experience of the services 
has brought it home to many people that here is a very consider- 
able problem. The illiterate soldier is of very little use in the mod- 
ern army. The illiterate workman in industry may be of more 
value but clearly he can never realize his full measure of capacity and 
he should be provided for. The dull man, under war conditions, is 
incapable of being trained to such a degree as to become a first-rate 



OPPORTUNITIES EMERGE 79 

soldier. It is therefore highly important that time and money should 
not be wasted in attempting to train him for jobs that he could not 
effectively do he should be trained for work within his compe- 
tence and thoroughly trained for that. Many men graded down for 
physical defects and many of the constitutionally inferior type are 
able to be employed on the routine, semidomestic jobs of the army 
after they are trained and taught to regard the simple jobs as some- 
thing that can be done well and efficiently and as having first-class 
importance for the war effort. For these men we have, in the British 
army, what might well be called a domestic workers' college, though, 
its "graduates" call it by its proper name, the Army Selection Train- 
ing Unit. Army experience brings home to one the necessity of train- 
ing for all sorts of jobs. The simplest occupations can be taught and 
should be taught because the fact that we have learned a skill and 
feel ourselves trained in something, however simple, adds greatly 
to our contentment and consequently to our mental health. There is 
a material proportion of the population that drifts from job to job 
whereas, in fact, there are very few jobs which are truly unskilled, 
though the degree of skill varies enormously. Armies teach men to 
dig and they teach men to sweep and in consequence these jobs get 
better done. 

Morale depends in part upon good training and it was noticeable 
at one time in certain primary training centres that men came in 
with a very good outlook, keen on the army and on their work, while 
after four or five weeks their morale was perceptibly less high. In 
consequence a good deal of thought was given to the reasons for 
this and the introduction of much greater realism into training went 
far to remedying the difficulty. As an illustration one may cite how 
some old-fashioned instructors were in the habit of teaching men all 
about their weapons, how to take them to bits, how to clean them, 
what the names of all the parts were before they ever allowed the 
men to fire them. No one would expect a small boy to be interested 
in his air gun until he had fired it; having done so he is quite keen 
to look after it, and the same holds true of an adult man. To use 



80 THE SHAPING OF PSYCHIATRY BY WAR 

weapons first and then to learn about them afterwards is clearly the 
right way and though it can hardly be called a major psychiatric 
discovery it is typical of the small points in which a psychiatrist or a 
psychologist can make suggestions for the modification of a training 
scheme. Similarly, in units of young soldiers coming into the army 
with high enthusiasm, there was a notable change when they were 
put on to boring jobs, guarding airports and vulnerable points, in- 
stead of doing as they wanted, which was to be trained and well 
trained. The crime and sickness rate of units like this was high but 
the picture was completely reversed once it was realized there must 
be a far more adequate place for good intensive training to utilize the 
enthusiasm and adventurousness of the young men. 

Certain problems, more specifically psychiatric, have emerged in 
other aspects of training. Enthusiasts at the modern battle schools in 
the army had decided that it was a good thing to inculcate hatred of 
the enemy and so a liberal use of slaughterhouse material was made; 
all kinds of aggressive activities were organized during training 
with the idea of stirring up hatred for our enemies, in the belief that 
it made better and keener soldiers. The psychiatrist who was asked 
to go down to help with these projects was fortunate enough to 
discover within the first few days that what might have been expected 
had, in fact, happened. Some of the men who had been the best and 
keenest students going through these battle school courses had after- 
wards lost interest and become rather ineffective; in fact they had 
gone into depression. The artificial stirring up of hate is certainly not 
a good preparation for battle; to stir it up artificially is about as 
sure a way of producing a reactive depression as any other. Similarly, 
in the teaching of first aid to soldiers in combatant units there has 
been a tendency at times to devise models of the most startling 
wounds, which are then strapped on to the casualties in an exercise, 
and to devise training films in which the blood from severed arteries 
spurts out about two feet in the air. Such pictures given to a man 
of imagination and intellect do nothing but scare him. They may 
in fact show what war conditions can do, but to confront him 



OPPORTUNITIES EMERGE 81 

with this is a poor method of preparing him for the realities of battle. 
A gradual introduction of unpleasant things is necessary in any form 
of training. The trouble always is that the instructor rather likes to 
demonstrate the importance of his own subject and at the same time 
his own toughness. If he can scare people by showing them striking 
and repulsive sights he feels that somehow he and his skill are thereby 



magnified. 



This same facet of the instructor was revealed very clearly in 
noise training at battle schools. Some psychiatric experiments (Mc- 
Laughlin) in the early days of the war during and after the Lon- 
don blitz had shown that carefully made gramophone records of 
battle noises did help certain people to abreact their experiences, 
and specially amplified records were used experimentally in com- 
mando training, while men were shooting at the miniature range. 
Little came of that experiment, but later when live ammunition and 
explosives were more easily available and began to be used as part 
of training, it was clear that they were being so used that they fright- 
ened men rather than the reverse. The psychiatrist at the battle school 
in consequence devised the principles of "battle inoculation" which 
have since been followed throughout the army. The important con- 
dition for the use of explosives during assault practice is that small 
"doses" shall be used first so that the men think little of them, and 
that then the severity shall be gradually increased so that finally, with 
dangerous major explosions, the men do not react unduly. The pur- 
pose of battle inoculation and training with live ammunition is to 
minimize the morale-destroying effect of enemy weapons that will 
be encountered in battle. War is an affair of morale and all weapons 
have, or should have, a morale-destroying effect: the dive bomber, 
the tank, the mortar, and, indeed, most weapons affect morale more 
than they take life. In training we want to debunk the noise and 
frightfulness of these weapons so far as it is safe and wise to do that. 

It was interesting to notice how, in the early days of the war, we 
failed to realize how the Germans were trying to undermine morale 
with their films. Baptism by Fire and the other films prepared for 



82 THE SHAPING OF PSYCHIATRY BY WAR 

neutral countries were all showing the might of the Wehrmacht and 
the terrible plight of those against whom Germany was fighting. We, 
in some of our films, whether they were news reels or training films, 
were tending to show big guns pointing at the audience instead of 
encouraging the audience to visualize themselves behind the big 
guns; we showed tanks looming up like monsters in front of the 
camera, reminding one of the civilians and others who were crushed 
by tanks on the roads of France, tanks running over British soldiers 
instead of Germans. The psychology of the photographic angle and 
of teaching through films is exactly comparable to the principles that 
hold in battle inoculation. There is, in fact, hardly any part of train- 
ing in which there is not some contribution to be made by anyone 
who thinks in terms of the human reaction to the training; and what 
is true in military training is no doubt equally true if translated into 
terms of civilian training. 

MORALE 

The actual word "morale" seems rarely to be used in times of peace, 
though in fact it can be well applied to the state of mind of any 
civilian group and not only to that of armies in wartime. It is es- 
sentially a matter in which the medical man, and, above all, the 
psychiatrist, is interested because while it might not be quite accurate 
to paraphrase it as mental health, it is in fact very closely related to 
it. There is a remark in one of Napoleon's letters which has often 
been quoted that "war is three-fourths a matter of morale; physical 
force only makes up the remaining quarter." l And few of us who 
have watched both the army and the civilian population in wartime 
have any doubt that this is true. The word morale tends to get loosely 
used and to become a newspaper catchword, but it is quite possible 
to make a correct assessment of the morale of a nation or a fighting 
force at any particular time. We have all known it to be outstandingly 
good in victory or indeed at times of great danger, as in the Battle 
of Britain. 

1 Correspondence de Napoleon 18, 14276, 1808. 



OPPORTUNITIES EMERGE 83 

Little of value has been written about morale as yet in this war. 
The book by Munson published in America after the last war was 
probably the most carefully documented and thought-out presenta- 
tion of the subject, but from our experience in this war we should 
be able to provide much more factual material which should be of 
use for all those who are concerned with the welfare of groups and 
communities. The war itself is not over and in its later stages, and 
certainly during the period of demobilization and resettlement, we 
shall have plenty of further opportunity for studying the meaning of 
morale and the methods of maintaining and improving it. The word 
morale is somewhat indefinable though to most of us it conveys the 
same concept: the individual morale of courageous men who have 
what colloquially is called "guts" and the team spirit of the group 
combine to bring about in a unit that effective attitude towards their 
task necessary for carrying it through. The will to win and the con- 
fidence in the purpose for which men are fighting so colour the atti- 
tude of the group that they constitute the most important factors in 
its life. Wars are won not by killing one's opponents but by under- 
mining or destroying their morale whilst maintaining one's own. 

The three main factors that make for good morale in wartime 
are adequate war aim and purpose, a sense of one's competence and 
value, and the feeling that one matters as an individual in a group 
of other similar people. This question of war aims has presented many 
difficulties during the present war and in every country there has 
been a struggle to translate ideologies and theoretical values into 
practical and understandable terms. Armies that have been fighting 
in their own country for the protection of their own homes, like those 
of Russia, have had less need for concern, and even the German army 
with its carefully built up propaganda has been given a more obvious 
and easily understood aim than the Allied armies have had. Hatred 
of one's enemy is of little value if it is artificially stimulated, and the 
positive purposes of war, the goals we aim to achieve if they are 
realistic and can be clearly and simply explained, have a much 
stronger and more vital appeal. We shall have a lot of practice after 



84 THE SHAPING OF PSYCHIATRY BY WAR 

the war during the phase of industrial resettlement in expressing in 
words the aims and purposes of our countries and also of the indus- 
tries in which men spend their lives. Those employers of labour who 
can set out clearly some worth-while objective with which their work- 
ers are in sympathy will clearly have gone some way towards getting 
good co-operation and good morale in their particular organization. 

A sense of competence and skill in our work is necessarily de- 
pendent upon good training and, behind that, upon good selection. 
A man who is in the wrong job is never likely to acquire that re- 
assuring sense of his own skill. Whoever the man and whatever the 
job he is doing, whether in war or in peace, he should be able to feel 
he is a master of his own particular craft and have a pride in it and 
he should also be given due appreciation for that skill. 

The third factor in morale is that there should be a sense of one's 
own value as an individual in the group, and this is largely a ques- 
tion of leadership and the officer-man relationship which can do so 
much when it is good to foster team feeling and the determination 
not to let the side down. The understanding and management of 
men with good welfare and individual care and responsibility for 
every man in the group are the best prophylactic against unrest and 
a sense of injustice and a consequent antagonism which destroys mo- 
rale. The unit that talks of its officers as "they" and not "we" is a unit 
that has never been integrated properly as a team, and in wartime, in 
the army, this is a major problem, for it is no easy task to teach young 
men how to become really adequate as officers and leaders and 
"fathers" of their men. The lectures designed in the Surgeon General's 
Office in Washington which are to be given to all officers of the United 
States army provide an outstanding illustration of what can be done 
by simple mental hygiene teaching to ensure a proper understanding 
and wiser management of men by their officers. Colonel Menninger 
will certainly have to write us a new version of these lectures after 
the war for civilian purposes, since industry is just as much in need 
of this kind of instruction as are the services. 

I quote here a summary from Fifth Column WorJ{ for Amateurs, 



OPPORTUNITIES EMERGE 85 

a pamphlet dealing with morale written by Lieutenant Colonel Wil- 
son, in a somewhat bantering style in order to catch the interest of 
the reader: 

SUPPOSE YOU WERE A NAZI AGENT 

Reverting to the title of this pamphlet; think of the things which, if 
done, would damage our army; think it over and don't do them! 

Damaging Trust in Leaders 

This is a relatively simple matter which may be accomplished 

(a) By display or abuse of officer privilege at a time when conditions for 
the men arc bad. 

(b) By failure to explain the significance of orders so that they appear 
inhuman and arbitrary. 

(c) By failure to explain sudden interference with leave, or other privi- 
leges. 

(d) By failure to take adequate disciplinary action when necessary. 

(e) By taking severe disciplinary action without investigating the cause 
of delinquency, or the defect of morale which lay behind it. 

(/) By sarcastic comment and criticism. 
(g) By failure to give praise where it is due. 

(A) By building up a facade of discipline without a basis in morale. (This 
is a particularly valuable act of sabotage since it will not be found out 
until action starts.) 

(/") By being too close on the heels of NCO's in their work. 
(/) By ignoring NCO's in their work. 

(^) By overestimation of the Nazis accompanied by boasting or inac- 
curate evaluation of our own values. 

(/) By displaying ignorance of our war aims and lack of interest in the 
army and its history. 

(m} By display of social or political bias, disguised, if possible, under a 
different label. 

(n) By dodging questions and discussion. 

(o) By making it clear in behaviour rather than speech that the war 
is an unwelcome interruption in a life of material gain and that one's 
main personal aim is to get back to the status quo as quickly as possible. 



86 THE SHAPING OF PSYCHIATRY BY WAR 

Damaging Group Morale 

(a) By breaking up groups of friends in platoons, barrack rooms, or de- 
tachments, or by blind posting, e.g. on an alphabetic system. 
() By changing men over so that they never get time to settle in one job. 

(c) By keeping an intelligent man in a boring job, and putting an un- 
intelligent or unsuitable man in a position of authority. 

(d) By boring men with routine instructions about parts of training 
which they already know well. 

(e) By being bored with training instructions yourself. 

(/) By instructing men more frequently and more intensively on the 
maintenance, rather than on the use, of weapons. 

Damaging Individual Morale 

(a) By failure to show interest or to encourage a man regularly. 

() By ignoring minor requests in relation to leave. (This can easily 

be done within the regulations.) 

(c) By refusing to listen to men's grievances or, better still, by paying 
little attention when they do come with them. 

(d) By making men be excessively fussy about relatively unimportant 
matters so that their interest is lacking in relation to more important 
affairs. 

(c) By writing to the men's families in an inaccurate or offhand way, or 
by not writing at all. 

"Suppose you were a Nazi agent . . ." is a valuable game to try in a 
mess. It has a moral. The moral is about morale. 

The indices of morale are somewhat difficult to discover and yet it 
is of the greatest importance that we should be able to assess the 
state of morale of any particular community. Where low morale 
exists it is practically certain that there will be a high sickness rate and 
also a high rate of delinquency. Absenteeism, whether from a service 
unit or from an industrial concern, indicates not only possible bore- 
dom with a job but also some lack of cohesion in the unit and a lack 
of purpose. Factors such as these, when they are available and can be 
charted or noted, undoubtedly give some explanation of the state of 
mind of the particular group. Opinion surveys are being used with 



OPPORTUNITIES EMERGE 87 

great advantage in all the armies to discover what men feel and how 
they react to their particular tasks or circumstances, and the morale 
committees which exist in all forces are able, by collecting and collat- 
ing such evidence, to understand better the feeling of their men and 
so to shape administrative action accordingly. The commercial firm 
that did no market research before it launched some new product on 
the public would be unlikely to succeed, and those who are responsible 
for the welfare and efficiency of armies have adopted similar tech- 
niques. Allowing for the manifold difficulties that crop up in the 
organization of a fighting force, these factors arc being taken into 
account in planning. Though we have gone some way in the right 
direction here it is quite certain that we shall not be able to obviate 
all the difficulties of social unrest that will be likely to come in the 
next few years, but after the war, with the fresh experience gained, it 
should be possible to do much more effective work in anticipating 
group reactions and designing the structure and administration of the 
group so as to ensure a higher state of morale. 

Certain special problems have arisen in war in connection with the 
forces overseas, and here psychiatry has been able to help a little in 
the designing of radio programmes and films to counter specific 
difficulties. Men who have been away from their home country for a 
long period get quickly out of touch; they are liable to be very sus- 
picious, somewhat resentful of what they hear from home or read 
when papers reach them, and it seems clear that this problem must 
always arise when men in large numbers have been away for more 
than two or three years. It became quite clear that for many of these 
men the greatest possible help would be to show them ordinary, simple 
pictures of what was in fact happening in England. Elaborate films 
with a propaganda flavour were resented. It was found that carefully 
planned documentary films of scenes at home not only showed them 
how war had changed the state of things, but also gave them a feel- 
ing of renewed contact with their own country which brought con- 
siderable reassurance and satisfaction. Similarly, radio talks specially 
designed to be descriptive and given by friendly, fatherly figures or 



88 THE SHAPING OF PSYCHIATRY BY WAR 

pleasant, ordinary women's voices were extremely effective, compared 
to some of the programmes which we have become accustomed to as 
being typical of the radio. There have been many valuable experi- 
ments made in the use of these media both in the United States and 
in Great Britain which have been highly successful and they have 
achieved this success because they have been prescribed and designed 
especially to meet the needs of men who are suffering from separation 
and a sense of isolation. 

It seems quite clear that psychiatrists have a greater responsibility 
than they have realized heretofore for helping in the future develop- 
ment of films and radio as a means of affecting public opinion. Where 
our understanding of a situation is sufficiently deep, we can prescribe 
the palliative or the remedy, and working on that prescription the 
film writer or the radio producer can get to work. Two excellent 
examples of films written to psychiatric prescription are The New 
Lot and The Way Ahead. The first was produced within the British 
army as a film for recruits joining up; it deliberately emphasized 
all their difficulties and grumbles and gradually dissipated them. It 
showed the way in which the group spirit developed and the gradual 
mounting of morale amongst recruits, and managed to do this with- 
out any suspicion of propaganda. The second film introduces the 
officer and shows the gradual formation and integration of the group 
with its interpersonal relations and the right kind of officer-man 
contact. None of the writing of this latter film, which was made by a 
commercial firm, was done by a psychiatrist, but the prescription was 
written by a psychiatrist and faithfully followed with a successful 
result. This probably is one of the first occasions on which this tech- 
nique has been worked out and it is at least suggestive as a method 
to be followed to help with some of the problems of social recon- 
struction. 

DISCIPLINE 

For long there has been an idea that the discipline of the army is 
what will "make a man" out of all sorts of inadequate problem people. 



OPPORTUNITIES EMERGE 89 

The discipline of armies is certainly a very important matter, and 
quite rightly so, because without first-class discipline no army can 
undertake the tasks with which it is faced. Discipline creates many 
problems for the individual who joins an army in wartime because 
he has necessarily to give up a good deal of his own freedom. It is 
therefore part of our job to see that the soldier understands and 
accepts discipline voluntarily and welcomes it and, indeed, prides 
himself upon his participation in the activities of a well-disciplined 
unit. While morale is a vertebral column that keeps us erect, discipline 
by itself is only a corset which can for a while hold a man erect. By 
that it is implied that without morale, discipline can never be really 
good, and it may even be dangerous. A unit which through poor 
welfare and failure in the quality of its officers and noncommissioned 
officers develops much discontent and crime may decide to tighten 
up discipline as a countermeasure, failing to see the real cause. What 
happens then is simply that the number of courts-martial and other 
disciplinary procedures increases rapidly, and while in the long run 
the unit may be cowed into a "disciplined" state, its morale and its 
value as a fighting unit will be destroyed. An increase in disciplinary 
measures cannot be an alternative to the development of good morale. 
In civil life equally threats, prosecution, and penalties do little to check 
absenteeism and strikes. 

Of necessity the regulations and restrictions of army life during 
training give rise to some discontent and in themselves lead to the 
commission of army crimes. The mentally dull man is, of course, 
particularly prone to commit military oflfences, partly because he fails 
to comprehend the regulations and the reasons for them, and partly 
because of a natural reaction against an environment in which he 
feels insecure and unhappy. The unstable man, who has possibly 
grown up in a broken home, has that same insecurity and he too 
finds difficulty in accepting willingly the rules and regulations of the 
new family into which he has come and he often is a major problem 
in the group. Both of these classes of men can be dealt with and, more 
often than not, satisfactorily helped within the army. The man whose 



90 THE SHAPING OF PSYCHIATRY BY WAR 

psychopathy has led to a bad civilian record of crime is extremely un- 
likely to do well in the army because he is fundamentally antisocial. 
He is often supposed to be a good fighter in a tough spot, but he is 
certainly a headache to his unit since more of the time is spent in 
training or in living behind the actual front line. 

Legal procedure in the British army, the only one which I know at 
all well is in some ways in advance of civil procedure. A court- 
martial is in many ways a more humane and understanding court 
than a police court, and by and large the army is more careful and 
wise in its justice than a comparable civilian court. Nevertheless there 
are, of course, many exceptions to the rule and many problems arise 
because the legal procedure of the army in wartime has to be applied 
by those who have little knowledge of it and who often have an 
inadequate understanding of their fellows. Psychiatrists in the army 
have, of course, a good deal to do with disciplinary cases and some 
quite useful work has been done in bringing the legal and medical 
points of view together. The lawyers have quite rightly always ob- 
jected to "trial by doctor" and the doctors have often felt that the 
lawyers lacked social conscience and indeed sometimes common sense. 
There is justice in both these points of view but there is a common 
outlook which can be reached and to some extent that has been 
brought about more in the army than anywhere else. There still are 
lawyers who talk of getting convictions as their "inalienable right" 
and there still are doctors who sentimentalize about a man's delin- 
quency and fail to distinguish between the offence that has been com- 
mitted and their respect for the man who has committed it. 

The situation in the British army with regard to psychiatric pro- 
cedures and disciplinary offences is that the psychiatrist is asked to 
see every man where the commanding officer or the convener of the 
court-martial thinks there is some reason to suspect that the man is 
not quite normal or was not so at the time the offence was committed. 
The report of the psychiatrist is made out on a pro forma reproduced 
below (pages 92-93) that aims to meet all the formal questions which 
are necessitated by the Army Act and by British law. In fact, of all 



OPPORTUNITIES EMERGE 91 

men who are brought before a court-martial about 18 per cent have 
been seen by psychiatrists and in only about 3 per cent of these has 
there been sufficient evidence to interfere with the holding of the 
court-martial or any suggestion that the man was unfit to serve a 
sentence. What does result, however, from this type of report is that 
full notice is taken of a man's unfitness as a soldier, in fact, of his lack 
of military value. The dull or psychopathic man may be fit to stand 
his trial and serve his sentence if convicted, and it may be from the 
point of view of the army as a whole very sound that he should do so. 
What often occurred previously was that when he had served his 
sentence he would return to his unit and once again be a useless 
soldier, certain to clog the works somewhere and to be in fact a con- 
sumer of manpower rather than a helper. Nowadays a man who is 
unfit as a soldier is recognized as such and is discharged or a suitable 
alternative posting within the army is arranged for when his sentence 
is completed or sometimes before that. The psychiatrist is not called 
for the defence nor is he briefed for the prosecution; he himself may 
occasionally appear but then as an expert witness and adviser to the 
court. This is a very desirable advance on the situation which arises 
so often in civil life where psychiatric or other medical judgment 
seems often to be warped by the fact that the doctor is called by one 
or other side in the trial. 

British army regulations have laid it down that all men in deten- 
tion barracks or military prisons who appear abnormal shall be seen 
by psychiatrists to advise on their posting or disposal at the end of 
sentence and in certain places committees are set up for the review 
of sentences with the psychiatrist as a member of the committee. 

In the army, military prisons and detention barracks are graded 
according to the type of man they receive and certain of them have 
become much more training camps than detention barracks in the 
old sense of the word. In addition to these there are special units 
both for young soldiers under twenty-one and for older men who, 
while not under sentence of any kind, are difficult people in their 
units. Men who go to these special units are those who have not 



92 THE SHAPING OF PSYCHIATRY BY WAR 

responded to unit discipline and do not seem to have learned from 
court-martial sentences or detention and who in consequence are more 
of a burden than an asset to their units. 

Absence without leave, as in all armies, is a major problem and a 
considerable proportion of the men of these special units have a his- 
tory which explains this particular difficulty. They either come from 
broken homes, are immature people, or they are men with welfare 
problems that have been neglected or badly handled in their units. 
First-class welfare and careful, friendly discipline and training pro- 
duce remarkably good results with these men and approximately 
70 per cent of them can be successfully posted after four to six months 
to ordinary units, not of course those from which they came. The 
follow-up on these men is carefully made and it seems clear that some 
permanent improvement does occur. Some attempt has been made 
to grade these men and send them to particular units which aim at 
dealing with conditions of approximately the same severity or prog- 
nosis, but up to date it has not been markedly successful. Theoretically, 
if one had a sufficiently well-trained staff for these training camps it 
would be of real advantage to divide the men up according to the 
nature of their difficulties and according to prognosis, but it is diffi- 
cult -in wartime to find the staff who can do this. 

FORM OF PSYCHIATRIC REPORT IN DISCIPLINARY CASES 

Note When, in the opinion of the psychiatrist, a man is clearly fit to plead and clearly 
responsible for his actions at material times, a brief report to this effect may replace 
Parts B and C of this report. 

Number Name Ref. 

Age Service Unit 

A. The above-mentioned, who is charged with 

has been referred for psychiatric examination. 
He complains that: 
He states that: 

On examination I noted that: 
In my opinion he is suffering from: 



OPPORTUNITIES EMERGE 



93 



B. Unfitness to plead due to insanity: 

(a) Is he able to understand the nature of proceedings at a court- 
martial? 

(b) Is he able to object to any member of the court? 

(c) Is he able to instruct his defending officer? 

(d) Is he able to understand the details of the evidence? 

C. Criminal responsibility: 

(a) Was he at the time of the alleged offence suffering from a defect 
of reason from disease of the mind? 

(b) Did such defect of reason prevent him from knowing the nature 
and quality of the act he was doing? 

(c) Or, if he did know, did he know what he was doing was wrong? 

D. Evidence as to character: 

(a) Was the accused suffering at the time of the offence from any ill- 
ness which might have affected his behaviour? 

(b) Is punishment likely to diminish the chances that he will repeat 
this or similar offences? 

(c) Is punishment likely to increase or diminish his efficiency as a 
soldier? 

E. Medical disposal: 

(a) Is any treatment required immediately, during detention or after 

release? 

() Is any other action recommended? 

(c) Any other relevant information? 

WOMEN'S SERVICES IN THE ARMY 

The use of woman power in the services has been much more 
developed in this war than in 1914-18 and in the British army it has 
been an unqualified success. One of the main differences between the 
fascist and the democratic cultures is in their outlook on women, and 
the fact that women can be integrated into the structure of the army 
and be so successfully employed alongside men is evidence of the 
democratic soundness of the army. It has often been suggested by 
some people that the acid test for the cryptofascist is his attitude to 
the employment of women and their place in society. 



94 THE SHAPING OF PSYCHIATRY BY WAR 

The Auxiliary Territorial Service has provided women for many 
types of job and the selection procedures both for auxiliaries and 
officers have been devised in a very similar way to those existing for 
men. Many special occupations requiring careful meticulous attention 
to detail arc better carried out by women than by men, and the accu- 
racy and quality of women's work with searchlights, radio location 
and other tasks in antiaircraft work have been very marked. The 
mixed batteries of men and women have been very successful. All sorts 
of doubts were expressed originally about the formation of such units 
but after a very careful assessment of all the possible difficulties they 
have been exceedingly efficient and harmonious formations. On the 
whole, sickness and delinquency rates of mixed batteries are less than 
for other units. Their morale is very high, there have been very few 
sexual difficulties and a good deal is being learnt that should be of 
value in the future for those who have the management of mixed 
teams of men and women in industrial employment. 

Some interesting phenomena arose soon after women began to 
take over radio-location apparatus. To understand these we should 
recall that both in the last war and in this it has been commonplace 
to find that fears of impotence are extremely common both in recruits 
and in soldiers generally. In recruits it is common for a rumour to 
spread that "something is put into tea to keep you quiet," and simi- 
larly among soldiers one of the greatest difficulties in administering 
quinine or mepacrine is the conviction that somehow it damages 
potency. Similar views are often held about such innocuous sub- 
stances as ascorbic acid tablets. Investigation strongly suggests that 
the relatively rigid discipline of an army produces in men fears of 
loss of initiative and competence which not unnaturally emerge in 
the form of phobias. In women, however, this situation took on a most 
interesting form. It had been noted that one of the reactions of com- 
ing into an operational unit, where the Auxiliary Territorial Service 
was used not for domestic or administrative duties but was directly 
concerned with the detection and attack on enemy bombers, was in- 
creased interest in what might be called "feminine matters of dress 



OPPORTUNITIES EMERGE 95 

and appearance." In discussion some of the girls made it clear that 
they feared that being in the army, especially in an operational role, 
might somehow harden them or defeminize them. Not unnaturally 
the complete change of life and customs led in some cases to transient 
amenorrhoea. The remarkable thing was that in these cases the girls 
did not make any complaint to the doctor at the time which was 
likely to arouse maternal or demonstrative anxiety. They complained 
conversely that radio-location apparatus was producing a sterilizing 
effect. 

It was easy to see that when attempts were made to deal with this 
by direct channels and reassurance the result was in some cases to 
spread the rumour further. Obviously the anxiety which gave rise 
to the rumour was widespread in these girls. The suggestion was 
made, and where it was carried out it apparently proved effective, that 
the best way to tackle this anxiety was to discuss the alleged hardening 
effects of a military life during the elementary hygiene lectures re- 
ceived by girls in early training. It was suggested that at this point 
it could be said that if any girl who was married wished to leave to 
have a baby this could be arranged, and that Sergeant X had in fact 
just returned from having her second wartime baby or some other 
example could be given to indicate that sterility was not a necessary 
complement of operational service in the Auxiliary Territorial Service. 
With the gradual increase of confidence and the sense of certainty 
about their place in the whole organization these fears of masculiniza- 
tion dropped completely into the background. In the same way the 
few waves of criticism of the women's services and the suspicions 
entertained by husbands and fiances serving overseas have receded 
completely, as could have been predicted. The women's service has 
established itself very firmly and its traditions and experience and 
acquired maturity will be a great stand-by in the nation's life after 
the war. 

The neurotic difficulties amongst women have been slightly more 
numerous than amongst men. It is an interesting reflection on the 
types of work that women undertake that such dull women as were 



96 THE SHAPING OF PSYCHIATRY BY WAR 

taken into the army were found to be more employable and more 
stable than men who were dull to a similar degree. Women who 
break down with neurotic difficulties are more difficult to employ 
than men partly because there are more restrictions on the number 
and types of employment available. 

EDUCATION 

At first sight it would not appear to be self-evident that wartime 
and army service provide opportunities for educational work, but in 
fact a considerable amount has been undertaken. Education in psy- 
chiatry has made some little progress. Apart from young medical 
officers who have had some regimental experience and perhaps a few 
months of mental-hospital training prior to entering the army and 
who have had three- or six-month courses at military psychiatric hos- 
pitals, other groups have also been given training. A great number of 
lectures and sets of lectures on psychiatric topics have been given to 
regimental medical officers and to those in general hospitals. The value 
of good brief courses for men who are otherwise good doctors has been 
proved both by the United States army and our own. In the United 
States army in England as well as in the United States courses of a 
month were given most successfully to men who were in training 
as divisional psychiatrists, while five-day courses for medical officers 
from regiments and general hospitals have proven their value. Reports 
from the invasion forces in Normandy make it quite clear how suc- 
cessful this kind of education, given to men who are already steeped 
in the army, has been. A week's course for medical specialists in the 
British army, which was primarily devoted to lectures and discus- 
sions on psychosomatic medicine, paid good dividends. The actual 
results of it could be seen, for example, in the Tunisian campaign 
where medical specialists were able to take charge of the treatment 
of large numbers of psychiatric battle casualties, and with their in- 
creased knowledge and interest in psychiatry make a more effective 
contribution to the general health and efficiency of the army. As was 



OPPORTUNITIES EMERGE 97 

noted in Chapter One the army in war is a very good place in which to 
get across to medical officers a sane and practical point of view about 
psychiatric cases. Perhaps some of our teaching in civil life might 
be made still more effective as well as still more productive if we 
could relate it rather more specifically to the more urgent everyday 
problems which surround the general practitioner or the civilian 
physician in the same way that neurotic and psychosomatic disturb- 
ances, human and manpower problems surround the army doctor. 

The training of nurses has also made some progress. I do not know 
whether this holds in other countries, but nurses who in civil life 
possessed the double qualifications of general and mental nursing 
seemed always to be anxious in the army to get on to general nursing, 
presumably as a change and relief from their prewar occupation of 
caring for psychotic cases. A considerable number of nurses without 
mental training have been given practical teaching and experience 
with neurotic patients and with psychotic patients also in the army, 
and in many cases have realized for the first time what valuable 
scope there is for a nurse in psychiatric work. 

General educational work for men and for officers also has been 
developed more in this war than in any other and from our angle as 
psychiatrists this is a matter of great importance. Not only do educa- 
tional courses, such as are now available in all the armies, provide 
a method of occupying leisure time, but they also make a very positive 
contribution to good morale and to efficiency. The specific training in 
army subjects is a matter apart, but through the psychiatrist to some 
extent and the psychologist to a greater extent considerable contribu- 
tions have been made to the design and supervision of teaching 
methods and to the development of new techniques of instruction 
(Stephenson). The more general educational work has spread to 
every unit in the army, including all hospitals and similar formations. 
It is as though branches of the Workers' Educational Association or 
some society for adult education were at work everywhere permeating 
the life of the whole army. The effect of this on patients in hospitals, 
giving occupation, interest and incentive, is entirely beneficial and it 



98 THE SHAPING OF PSYCHIATRY BY WAR 

seems strange that hardly any hospital in peacetime had an adequate 
educational organization at work even amongst long-term patients. 
The army's experience would seem to suggest the value of such pro- 
cedures for the future. 

One section of educational work has been the development of the 
Army Bureau of Current Affairs which has arranged for definite 
hours for discussion groups fitted into the ordinary training time. 
Those have very considerable value. Fortnightly booklets covering 
the basic features of some particular topic from actual military opera- 
tions to social reconstruction and economic theory are provided for 
the officer who acts as chairman and guide of the discussion. The 
meetings are most productive and democratic. These ABCA discus- 
sions provide an opportunity for men to express themselves, to get 
grumbles off their chests and to learn through talk and argument 
with others a great deal about subjects otherwise quite foreign to 
them. Quite indirectly the morale factors are stressed, and nothing 
but good results from these discussions. It is interesting to find that 
even before the war is over the same technique has been introduced 
into industry, in some cases linked with the production committees of 
factories, and it is understood that there too these meetings are pro- 
ducing excellent results. Perhaps the army is better educated than the 
last civilian army of 1914-18; certainly it is more thoughtful and 
there is no question that from many angles, including that of psychiat- 
ric prophylaxis, these free discussions, which act sometimes almost 
as group therapy for unrest and discontent, serve a very useful purpose. 

AREA PSYCHIATRY 

Of all the opportunities that have been taken in the army none 
has been more profitable from the angle of mental health than the 
chance of placing psychiatrists to work in and be responsible for areas 
or large formations. In America, the replacement training centres 
undertake this type of work. In Canada there are area psychiatrists 
and in the British army, in addition to area psychiatrists, there have 



OPPORTUNITIES EMERGE 99 

been corps psychiatrists, and in some places divisional psychiatrists 
also. The psychiatrist who is tied down to a hospital routine and 
whose patients come to him for diagnosis and treatment does very 
useful work but he is shackled and less useful than when he is free 
of ward duties and able to get around amongst units and formations, 
hearing their problems, helping where he can, contacting officers and 
discussing their men and their difficulties with them. In Chapter One 
some indication was given of the training adopted for these men and 
it was emphasized there that the men to do this are those who have 
a good personality, are good mixers and who have a sound knowledge 
of psychiatry in addition to sociological interests. 

The area psychiatrists work very much as a team in each command 
at home and overseas and have provided the cutting edge of military 
psychiatry. Their knowledge of the army is extremely good and the 
contributions to its efficiency which have derived from their investi- 
gations and suggestions have been numerous. Their outpatient work 
is sounder because of their contact with units and their help in selec- 
tion procedures is greater because of their understanding of the con- 
ditions in which men work. Unless psychiatry in the future is to limit 
itself to diagnosis and treatment of patients, it must have some equiv- 
alent for what we call area psychiatry. The progress of social or 
preventive psychiatry will be far greater if some such organization 
be brought into being. 

SPECIAL ENQUIRIES 

Many opportunities present themselves for special enquiries which 
are of scientific and psychiatric interest and it is important to take 
advantage of them. Had there been more time or, conversely, more 
psychiatrists available, the number of projects which could have been 
usefully followed up could have been multiplied many times. It has 
already been recorded that a very efficient research department with 
psychiatrists and psychologists working together has grown up in 
connection with the officer selection work of the army; and closely 



ioo THE SHAPING OF PSYCHIATRY BY WAR 

linked to that is the carefully controlled follow-up work of various 
groups which will, by the end of the war, provide us with many use- 
ful data. Psychiatry can provide some help and occasionally a new 
slant on the problems of other branches of medicine and in the army 
this has been possible fairly often. It is not that the psychiatrist has 
any wish, and certainly no claim, to take over anyone else's job or to 
magnify his own speciality, but in so far as he can point out or 
elucidate the psychodynamic factors at work in some disability or 
group of diseases he makes a valuable contribution to the work of 
his colleagues. Dermatology and orthopaedics are very typical exam- 
ples of this since here the emotional factors play a very obvious part 
in the causation of many of the conditions with which they deal. The 
army provides so many acute situations where manpower is being 
wasted that any help in selection, classification or treatment of cases 
which can be given is of special value. 

Early in the war some mild outbreaks or epidemics, as they might 
almost be called, of dyspepsia were shown to be entirely the result 
of emotional stresses on first joining the army, and throughout the 
early days of the war when dyspepsia was a major problem (which it 
has now ceased to be) there was a growing realization of the part 
played by emotional factors. In consequence these cases were, to a 
greater degree, kept out of hospital, many of them were handled 
much more wisely and much greater emphasis was laid on a psychiat- 
rically oriented approach to them. 

Some useful work has been done on limbless men by Wittkower 
and this is a matter where much more study is needed because the 
problem of the cripple is going to be a very considerable one after 
this war. Whereas in the last war so many men with serious limb 
injuries died, in this war because of the sulfa drugs and penicillin 
they are recovering; but they will be crippled and as a group they will 
certainly deserve special understanding. Wittkower's work was largely 
on the personality types and the varied emotional reactions made to 
injury and its aftereffects. Some 15 per cent of his patients were 
primarily depressed, 21 per cent reacted with resentment, 5.5 per cent 



OPPORTUNITIES EMERGE 101 

with anxiety, 21.5 per cent with defiance, 24 per cent with cheerful- 
ness, while a few more showed merely resignation. About 50 per cent 
of the patients examined showed psychological reactions sufficient 
to interfere with their social happiness, adaptation and occupational 
efficiency. The previous personality of these patients was studied and 
related to their emotional reaction to injury and clearly it was largely 
responsible for it. The problems of the attitude towards the artificial 
limb and towards the job as well as the social situation created by 
injury were studied and a number of suggestions which are now in 
course of further trial were made as to the better management and 
careful choice of employment for these men. 

This work on limbless men, other work on the blind and the par- 
tially sighted, whether re-employed in the army or going back into 
civil life, and a more fundamental study of the scientific bases of 
rehabilitation (Emanuel Miller) are being undertaken in the hope of 
gathering from war experience something of permanent value for 
peacetime social medicine. 

Studies of men serving sentences in detention barracks (Rudolf) 
and the problem of the type of man that gets venereal disease and 
why he gets it have been made amongst many others and they deserve 
mention. They have been relatively small studies because they were 
mostly done by one individual, but they reveal a prima-facie case for 
much wider study on a much larger scale. 

PRISONERS OF WAR 

Of all the socio-psychiatric enquiries that have been made amongst 
groups in the army, one of the most useful has been the investigation 
(Wilson) of the problems of prisoners of war returned from Germany 
and Italy. Considerable groups of men who have been repatriated 
have been very carefully studied, their problems noted and a follow- 
up made on their progress after return. The importance of this group 
of men with their special difficulties is not merely determined by the 
fact that there will be a very considerable number of them returning 



102 THE SHAPING OF PSYCHIATRY BY WAR 

to Great Britain after the war, but also their problems are in some 
measure typical of those which will be the common lot of many of the 
men who have been soldiering overseas for a long period. There seems 
a consensus of opinion, which is in part borne out by some statistical 
evidence (a sharp rise in welfare enquiries, marital difficulties, etc.), 
that eighteen months to two years after separation from home either 
on active service or in a prison camp marks the beginning of a certain 
deterioration of attitude. Two to three years of absence would seem 
to produce the largest group of difficulties. 

Our observation of repatriated prisoners has shown that after the 
first excitement and happiness at getting home there tends in a con- 
siderable number of cases to develop a certain depressive apathy, in 
some cases an actual depression, and that in addition to this there are 
evidences of discontent, bitterness and awkwardness sufficiently well 
marked to be forced upon one's notice. There is, of course, a certain 
proportion, about 10 per cent, who arc either physically or mentally 
so sick that after care in hospital they are thought to be unfit for return 
to the army and so are discharged on medical grounds. Of the rest, 
from the samples that have been followed up, one can probably 
estimate that 20 per cent will have marked difficulty in the process 
of resocialization and reintegration into life in the army or life at 
home. There seems to be some evidence for saying that the great 
majority of the balance of these men experience some difficulty and 
that there is a lapse of approximately six months before they feel them- 
selves once again settled down securely as part of whatever com- 
munity they are in. 

Separation from home and from any real participation in home life 
and wartime change is probably the chief factor in creating this dif- 
ference of outlook between the repatriate and the folk at home. The 
prisoner has been cut off from news, however good his correspondents 
have been. He has made all kinds of phantasy pictures of home but 
has not been able to allow at all adequately for the changes that the 
passage of the months and years have brought about. He arrives back 
and finds, after the first few weeks, how different many things are. 



OPPORTUNITIES EMERGE 103 

The social setting, the habits of people have changed, and this is of 
course more true in England than it would be in America. He finds, 
too, that his nearest relations and family have developed to some 
extent and grown away from him in their interests and outlook just 
as he himself has changed and grown independently. This is true 
of the repatriate and it is true of the soldier who has been long over- 
seas. There would seem to be very great wisdom in the plan which 
one of the dominions has made by which every man on demobiliza- 
tion from the army will have free travel for himself and his wife for 
a month. Even a brief holiday together may provide, through a second 
honeymoon, some small basis of common experience and common 
interest on which to start refashioning family life. During the period 
of absence a good deal of misunderstanding has tended to develop. 
The soldier shut away in Germany or fighting overseas becomes nat- 
urally rather critical of conditions at home and the way in which 
people live because the whole background and the setting are different 
and therefore not appreciated. Though at home they may have worked 
just as hard or even harder, the soldier feels that they are having an 
easy time. He is rarely critical of his own relatives in this way, but he 
thinks of "them," the others who are not having to undergo his 
stresses and privations. 

The prisoner of war has special problems which may lead to his 
deterioration. In the long, unoccupied hours he has had time to brood 
and have those tiresome second thoughts that come to most people 
about what he might have done better, or how he might have been 
wiser and more adventurous at the time he was taken prisoner. A 
certain guilt develops and this has been fostered to some extent by 
the fact that a number of relatives and friends at home have written 
letters rather implying that they regard a man who is a prisoner as 
in some way a quitter. Nothing could be more unjust save in an in- 
finitesimal number of cases, but it must be remembered that the fact 
of separation and loss of any real contact produces a similar effect 
on those left at home to that produced on the man himself overseas. 

The returned prisoner is very much afraid, and sometimes with 



104 THE SHAPING OF PSYCHIATRY BY WAR 

reason, that it will be forgotten that during the years of his absence 
he has grown, got more experience, worked hard at various occupa- 
tions, either physically or intellectually. It is not merely the prisoner 
of war, but also the soldier after overseas service to whom this applies 
and it is one of the many points that will have to be remembered on 
their reabsorption into industrial and communal life after the war. 

The repatriated prisoner, more than the serving soldier, is sensitive 
to authority and very anxious to get a convincing demonstration of 
the justice of his own countrymen on his return. He has for a long 
time been an expert at evading and blocking authority and if on 
return he gets the sense that he is not getting a fair deal he will cer- 
tainly turn out to be an expert "awkward." He demands, and so does 
the overseas soldier, special consideration and understanding although 
he does not want any obvious fuss or any overt expression of the 
special understanding. What does seem to help most is the feeling 
and the proof that people care about him as an individual, that in- 
dividual effort is made on his behalf to reassure him about his health, 
to get him into a job, to deal with his welfare problems and generally 
to build afresh in him the sense of being an individual who matters in 
a group that cares about him. There are going to be many difficulties 
in providing the special care that will be needed for these men when 
they return or are demobilized. They need a bridge provided by 
special understanding between the overseas station or stalag life and 
their new conditions at home. If we fail to give them this we shall 
undoubtedly have a lot of unrest to deal with and though this may 
very likely be put down to communism or other dissident influences 
it will, in fact, be due to the community's failure to recognize and 
allow for the changes in personality and outlook that these men have 
acquired. Everything that can possibly be done in the way of quiet, 
unfussy competence with kindly thoroughness in the management 
and resettlement of these men into civil life will pay handsome 
dividends. 



OPPORTUNITIES EMERGE 105 



PSYCHOLOGICAL WARFARE 

This phrase has been somewhat loosely used to cover a very vary- 
ing group of activities in this war designed in part to support the 
morale of our own forces and in part to undermine that of the enemy. 
Many of the activities of this type clearly cannot be written about, 
but it is important to recognize that the psychiatrist has a part to play 
in this field and that, in fact, he has been able to make considerable 
contributions. Not only by the introduction of selection techniques of 
various kinds for particular groups of men for the varying jobs, but 
also in more individual ways the technique of psychiatry has been 
found of value. Careful investigations and studies of the psycho- 
logical factors operating under diflerent circumstances in the German 
and Japanese forces have been made. Whether these will ever be 
published for general reading is not certain, but they have been of 
material value, and could only have been produced by men with a 
training in analytic psychology. Out of them has come much that is 
positive for the planning of present activities and for the shaping of 
postwar activity in occupied territory. The psychiatrist who has 
learned his national psychologies and pathologies has some contribu- 
tions to make to the international therapeutics that we shall need to 
employ after the war if we are to avoid its recurrence. Countless situa- 
tions will arise in which it would seem that the only way of avoiding 
errors of judgment in the handling of occupied or liberated countries 
is by calling on a body of knowledge carefully acquired through the 
study of the individual and group reactions of the people concerned. 
We know all too little, and yet we know enough to be sure that not 
only the work of an organization like UNRRA but many of the larger 
sociological and political decisions of the future demand this kind of 
advice. 

With the individual neurotic or difficult patient it is all too easy to 
say "pull yourself together," but the advice is fruitless unless we can 
tell him what to get hold of and how to pull. That we can only do if 



106 THE SHAPING OF PSYCHIATRY BY WAR 

we understand the psychopathology of the man himself. Similarly 
with groups of nations recovering from a traumatic experience there 
must be the fullest possible understanding before we can hope for 
successful efforts at self-cure, and unless we have it there will be a 
danger that the doctor may cause more diseases than he cures. 

BREAKDOWN AND TREATMENT 

Since in this chapter we are discussing the special opportunities 
that have presented themselves to psychiatry in the war, treatment 
has been left to the end. A good deal has been written about it but 
comparatively little that is really new or of great value has emerged. 
Treatment has on the whole been regarded in the army as having a 
less high priority than the prophylactic tasks of psychiatry such as 
selection, although when as at the present moment the neuroses aris- 
ing under battle conditions are to the fore, treatment is a first priority 
because of the urgent necessity and the high probability of getting 
men back to their jobs rapidly and usefully. 

Of the psychotics there is little that one need say. Their incidence 
has been lower than was anticipated and in the British army we have 
been able to keep them in the army for a period up to nine months 
if necessary while they have treatment in military hospitals. This has 
avoided certification or Unduly rapid discharge. In fact, in areas like 
the Middle East where the question of transport home was an ex- 
tremely difficult problem many recovered psychotics went back to 
duty and did well. The recovered psychotic is often a better bet than 
the partially recovered psychoneurotic. On the whole, however, the 
army's ordinary practice has been maintained and most men have 
been discharged from the service after a psychotic breakdown save 
that where the man had a previously good personality and a fairly 
obvious precipitating cause for his illness, made a good recovery fairly 
rapidly and had qualities that could be well used in the army, he may 
be retained. 



OPPORTUNITIES EMERGE 107 

TABLE 4 

Disposal of Inpatients on Discharge from Military Psychiatric Hospitals * 

To 

To To Civil Other Died, Ab- 
To Civil To Care of Mental Hospi- sconded 
Duty Life Relatives Hospitals tals etc. Total 
Psychosis 7.4 26.9 38.5 7.5 15.0 4.7 100.0 
Psycho- 
neurosis 36.4 47.3 4.7 1 1.2 0.4 100.0 

Note These figures bear no relation to the successful work done in hospitals overseas. 
They concern hospitals in the United Kingdom and the patients were either those 
breaking down in training in Britain or else those evacuated from overseas forces for 
disposal in the United Kingdom. They include therefore the failures of the overseas 
hospitals without their successes. 

* The percentage figures are based on a group of twenty thousand patients. 

Table 4 gives some idea of the disposal of cases of psychosis, and 
the low figure (7.5 per cent) of cases which had to be sent to the 
overcrowded civil mental hospitals of Great Britain may perhaps be 
an encouragement to us in stressing the wisdom of early treatment 
for the psychotic. In the army, of course, a man's disability is quickly 
brought to notice in most cases and once it is recognized he gets active 
treatment very rapidly. In every army, we are aware that psychotic 
episodes crop up with apparently greater ease than in civil life, but it 
is quickly borne in on us that the atmosphere and culture in which 
the man lives and to which he has become accustomed has a helpful 
therapeutic effect if he is treated in a military hospital. A follow-up 
is being carried out which will extend for some years after the war so 
that we may see how the results of very early treatment turn out when 
viewed from a distance and over the whole group of the psychoses. 
Obviously the results will not look quite as cheerful as they do in this 
table. Nevertheless, at the present time, after nearly five years of war 
the proportion of pensions awarded in Great Britain to these men is 
less than one quarter of the figure that obtained at the same period 
of the last war. 

The figures for the disposal of psychoneurotic patients given in 
Table 4 do not make very cheerful reading. It should, of course, be 
understood that they do not refer to men breaking down with acute 



io8 THE SHAPING OF PSYCHIATRY BY WAR 

battle neurosis, though a few serious long-term cases from overseas 
are included in this group of patients. The figures derive from the 
group of the more predisposed and chronically neurotic men in the 
army, many of whom have gone to hospital in order to have their 
superadded symptoms removed and be brought back to their sup- 
posed prewar level, or something better, if possible, before discharge. 
Where, even amongst this group of men who break down during 
training or service at home, there has been selection of the more 
hopeful cases, military neurosis centres have for months on end 
shown an 80 per cent return to duty. Nevertheless it is as well to 
accept the fact that the over-all picture for this group of men is not 
very rosy. The army in wartime has neither got the psychiatrists 
available nor the time to devote to prolonged individual treatment, 
and in any case, a high proportion of these men breaking down with 
psychoneurosis were below the median in intelligence. 

Throughout the war the invaliding rate for all psychiatric disabil- 
ities has been something over 30 per cent of that for discharge from 
all medical causes, varying of course according to the frequency and 
the size of convoys of men sent from the overseas forces for discharge 
in the United Kingdom. This discharge rate seems to be very com- 
parable with that in the Allied armies. 

A good deal has been written about this type of case and except for 
the emphasis on the factor of separation anxiety in lighting up these 
neurotic states, there is little new to record. The predisposition of 
nearly all these men is quite marked though varying in degree. Never- 
theless, many of them have given good and prolonged service and 
it would have been a mistake to exclude all men from military service 
who had any recognizable predisposition. It will be remembered that 
in the large group of British pensioners, some one hundred thousand 
of whom suffered from neurotic illness in the last war, there had been 
an average of eighteen months of foreign service. While it is better to 
err on the side of utilizing men with neurotic difficulties, none of us 
in the army has any doubt about the lack of clinical acumen which 
allowed a great number of these men to be passed into the forces. 



OPPORTUNITIES EMERGE 109 

That is a challenge to our medical educators, and from the experience 
of the armies in all countries there is some note of urgency in the 
challenge. 

The amount of individual treatment that it has been possible to 
give to men in hospital has been small. Probably very few of those 
who needed it have had more than six or seven hours of individual 
psychotherapy during their average of forty days' stay in hospital. Use 
has been made in most hospitals of continuous narcosis, modified 
insulin and sedation when necessary, and group therapy has made 
some small progress in its development. Occupational therapy has 
proved to be of value although there has been a general tendency to 
change its form and method of application. That very sound principle 
of resocialization which is carried out so strikingly by Burlingame in 
America has been in our minds and we have tended to veer away 
from the crafts and those other occupations that are best suited to 
the long-term case in bed or in the wards to more practical occupa- 
tions which keep a man in an active mood and eventually lead him 
back to military duty. Paramilitary games and pursuits, physical 
training, map reading, signalling, etc. have been much used and with 
considerable advantage. Training officers, educational staff and phys- 
ical-training instructors play a large part in the reconditioning and 
reintegration of these men to their military tasks. 

Reference was made in the last chapter to the scheme for special 
posting for neurotic men and women to jobs within their special 
knowledge and competence. Psychologists and personnel selection 
officers have been increasingly brought in to help in this procedure. 
Working within the psychiatric framework, the personnel selection 
officers can take full cognizance of such limiting factors as the psy- 
chiatrist points out for each particular patient. That has proved an 
extremely successful adjunct to treatment and a method of maintain- 
ing a man's efficiency and avoiding further stress and breakdown. 
Many thousands of predisposed and chronically neurotic men are 
doing full time effective work in special postings in the army at the 
moment. Had these men not been fitted into such special jobs they 



no THE SHAPING OF PSYCHIATRY BY WAR 

would have had to be discharged and so become a dead loss of trained 
men to the army. In civil life where this problem of the chronic 
neurotic is always with us we shall certainly find that greater use of 
selection and vocational advice will help us to deal with the social 
and economic problems where we have to accept our inability to per- 
form the ideal cure by an internal readjustment. 

We have had an interesting comparison during this war in England 
between two different types of hospital. Because of the peculiar stresses 
which were visualized at the beginning of the war, the powers that 
be decided that civilian hospitals should be set up under the Emer- 
gency Medical Service which would deal with service cases as well as 
with the large number of civilians who, it was anticipated, would 
need their services. From the beginning, therefore, we asked ourselves 
whether civilian doctors and the static civilian setup of the EMS hos- 
pital would produce better or worse results than a military hospital 
could achieve; here I am only speaking, of course, of the psycho- 
neurotic cases. So far as one can judge after five years' experience the 
EMS hospitals have one great advantage in a stable and adequately 
arranged staff. Their personnel does not shift like the military per- 
sonnel, and because they were civil hospitals run by existing civilian 
authorities they have had certain administrative advantages. The civil- 
ian psychiatrists can give their whole time to professional work. In an 
army hospital there are certain inevitable military duties which take 
some time. These civilian hospitals quickly found that they needed 
certain help from the army to deal with these cases and physical-train- 
ing instructors, noncommissioned officers for disciplinary purposes, 
educational sergeants and others were introduced. The best of these 
hospitals where they have made real efforts to understand the army's 
point of view and to work with and for the army, minimizing the 
civilian influence, have produced extremely good results, slightly 
better in fact than the military psychiatric hospitals. But that is not 
true of all of them, and probably over all it would be better to have 
any man whom it was hoped to send back to the army under care in 
a military hospital all the time and only use civilian hospitals for the 



OPPORTUNITIES EMERGE in 

necessary rehabilitation of those who are going back to their civil 
occupations. 

BATTLE NEUROSIS 

There are still some people, and alas some of them are doctors, who 
believe that no man should break down in battle and certainly no one 
should be "allowed" to break down. Behind this belief is the idea 
that somehow courage and cowardice are alternative free choices that 
come to every man, overriding all emotional stress, that a man can 
choose which he prefers or that he can be courageous if he is told he 
must be. This again is a reflection on our past failures to give a sensible 
education to laymen and indeed to our own colleagues, but it can be 
recorded that compared with the last war things are very much better 
and there is far more understanding in the army with which I am best 
acquainted. Nearly all training manuals do refer to the fact that fear 
is a universal and in its right place a beneficent reaction, but it takes 
a good deal to live down the early teaching of childhood. And the 
textbooks have been unheeded by those who are themselves ashamed 
and frightened of their own feelings of fear. It is interesting to note, 
however, that men are on the whole less scared of being afraid and 
consequently more inclined, when they do crack, to react by straight 
anxiety rather than by the development of conversion symptoms. 
That is certainly some small advance. But we have inevitably got a 
residual problem that we are never likely to resolve completely in the 
correct management of anxiety and fear. 

There is no doubt that the man who is breaking down with acute 
anxiety is very bad for his unit and likely to "infect" other men. Those 
who have up to that time been controlling their anxiety reasonably 
well must of necessity have it revived since they share to some degree 
the emotions of their colleagues. The air-raid wardens in London in 
the early days of the war were often advised, if people panicked in a 
shelter, to knock them out. The same advice holds true in the front 
line, and if sympathy and friendly firmness do not work then it is far 



H2 THE SHAPING OF PSYCHIATRY BY WAR 

better to get rid of the man for a short time and knock him out with 
sedatives for his own and everyone else's good. Whether it is the task 
of the doctor to decide where uncontrollable fear ends and cowardice 
becomes dominant is still an unsolved issue. There certainly are cases 
of cowardice with deliberate evasion of dangerous front-line duty, 
but most people are hesitant, and I think rightly so, to attach the label 
of cowardice or lack of moral fibre to a man showing any of the 
physical signs of anxiety: they are difficult to create artificially. All of 
us are nicely balanced between courage and cowardice and we find 
ourselves with anxiety controlled, expressing itself only through the 
autonomic nervous system; yet there must for many come a time when 
courage however well cultivated and maintained fails to operate. 
There is a story, which I believe is accurate, of Marshal Ney who, 
standing watching a battle, found his knees knocking together. He 
looked down at them and said, "Go on, knock, its nothing to what 
you'd do if you knew where I was going to take you in a few minutes." 
Whether that is a schizoid or a courageous reaction it is certainly 
typical of experiences that have come to most of us who have been 
in battle, though perhaps we were not quite so effective. Broadly 
speaking, it is true that any man may break down, granted that 
there are sufficient predisposing causes in the way of lack of sleep, 
inadequate feeding and constant stimuli through enemy bombard- 
ment. Obviously the man who has made friends with his fear, the 
man who has a high personal morale, and the man who is well 
trained and happy in a well-disciplined group will manage his fear 
better than the man who has not got those qualities or circumstances. 
Many men with well-marked neurotic predispositions stand up for a 
long time to the most trying front-line fighting, but on the whole, the 
inadequate man and the dullard crack very quickly and are better 
excluded. 

There is a very difficult eugenic problem for which no one as far as 
I know has found a solution. It is a worrying thought that our best 
men have to be killed in battle or in many cases mentally broken by 
their experiences while the inadequate remain unscathed at the base 



OPPORTUNITIES EMERGE 113 

or at home. If war should ever come again perhaps this problem may 
be varied since we may rely entirely upon aerial torpedoes, and hand- 
to-hand combat will be relatively uncommon. 

Another serious problem is that of desertion and how it should be 
dealt with. The abolition of the death penalty for desertion in face 
of the enemy appears to be linked with the relatively small number 
of self-inflicted wounds. Those of us who had to have firsthand 
experience of the men who were shot at dawn in the last war feel 
that we can perhaps understand that, since these men were in many 
cases quite obviously suffering from an acute neurosis. Whilst there 
have in this war been some evidences of men who lightly claimed to 
suffer from anxiety neurosis there certainly has been no epidemic or 
any suggestion of that. In the few cases where there have been "mass" 
desertions, i.e. quite a number of men at one time, there has prac- 
tically always been some explanation to be found, usually in faulty 
handling by NCO's or officers. To some of the tougher soldiers who 
declaim about the supposed kindheartedness of psychiatrists, one is 
tempted to say, "I thoroughly approve of shooting provided you shoot 
the right man." The fire-eater who regards all nerves as "fiddle-sticks" 
and anxiety as malingering normally lives at the base, and in practi- 
cally every case that I have met is recognizable without much difficulty 
as a man carrying a considerable load of personal anxiety, and shame 
about it. 

Clearly, the amount of breakdown that is to be expected under 
battle stress must depend on the kind of war that is being fought at 
the moment. Fluid war in the desert where we were winning pro- 
duced very little neurotic breakdown even though there was a good 
deal of physical fatigue. The figure on many occasions in the desert 
was as low as 2 per cent of the total casualties. The nearer the fighting 
approximates to the 1914-18 trench warfare the higher becomes the 
incidence. Where men are constantly suffering from weapons they 
dread most, like the multiple mortar or the 88-mm. gun, where they 
are separated from each other in fierce battle and are without sleep, 
the rate rises to 10, 15 or even 20 per cent. The better instruction of 



U 4 THE SHAPING OF PSYCHIATRY BY WAR 

regimental medical officers and of combatant officers in the early 
recognition of signs of strain has been of proven advantage. Where 
men are sent down to the regimental aid post for a night's sleep be- 
fore they have really cracked there is a good chance of avoiding that 
altogether. The organization of divisional rest centres is extremely 
successful and in the recent invasion of Normandy, the divisional 
rest centres and the corps exhaustion centres, which took the cases 
the divisional centre had found too difficult, were together returning 
65 per cent of the men to full combatant duty in six to seven days. 

Though this front-line treatment may be a doubtful form of "cure" 
and the bill may come in to these men after the war, it would seem 
likely that for many men this recovery from one bad attack of 
anxiety with a certain fresh orientation to fear may have a reason- 
ably lasting therapeutic effect. Hanson with the United States forces 
in Tunisia found that 89 per cent of a group of men so returned 
fought well for a further three weeks without breaking. We have 
found from the Normandy experiences that a considerable propor- 
tion of the men who cracked were those who had had marked 
anxiety in the fighting in North Africa, Sicily or Italy, but had not 
broken to such a degree as to have treatment. 

The importance for the efficient use of manpower of the reallocation 
of men to suitable jobs is very evident. In all overseas forces the re- 
habilitation groups at the base where the personnel selection staff can 
function are doing excellent work with those men who cannot be 
returned to front-line duty after rapid treatment. 

No force has, alas, gone out from Great Britain into battle having 
been completely through the selection machinery with psychiatric 
weeding out of the doubtfuls. Selection started late, and a variety 
of difficulties and obstructions has arisen to prevent the carrying out 
of the thorough procedures we wished. We therefore cannot produce 
any clear-cut evidence of the effects of selection procedure upon the 
breakdown rate such as Gillespie is producing in air crews of the 
RAF. We do know that particular formations where the commander 
has insisted upon very careful sorting have done exceedingly well 



OPPORTUNITIES EMERGE 115 

in battle and have had an outstandingly low rate of psychiatric casual- 
ties. We know equally that units that were much below the standard 
that they should have had on selection testing (i.e. with a high pro- 
portion of dull men and too many dull noncommissioned officers) 
have produced very bad figures with regard to breakdowns. Whether 
our attitude to the neurotic be "treat 'em rough" or "treat 'em soft" 
is equally irrelevant. What really matters is the quality of the man, 
the nature of his job and the type of strain that he is to undergo. 
The job of the army is to evaluate these and to modify as many 
as may be possible and so to prevent breakdown. Where prevention 
fails we must organize the most effective and rapid treatment. 

The use of the term "exhaustion" as a euphemism for all psychiatric 
breakdowns in the line has, on the whole, been very successful. Shell 
shock or even anxiety neurosis have a much more serious implication 
of illness than the label "exhaustion." The man who is sent to the 
division or corps exhaustion centre and after a few days is able to 
return to duty goes back with no diagnostic label, even though he 
recognizes that "exhaustion" was actually an alternative name for 
what he knew he had anxiety that brought him near to the end 
of his tether. The proportion of cases of actual physical exhaustion 
which come back and turn out to have no noteworthy psychiatric 
features is very small. 

Prophylactic sedation for men who are near to cracking is ex- 
tremely valuable. The barbiturates have averted many a crack 
amongst civilians in bombed cities and amongst soldiers in action. 
In small doses the quickly excreted barbiturates have no effect on 
military efficiency and even if they did they would, like the rum 
ration, do less harm to the man's efficiency and accuracy as a soldier 
than the anxiety which they relieve. Sedation for men who have to 
be sent down to the base or, as in the early days of Normandy, have 
to be sent across to England is of value in preventing a conditioning 
to anxiety with consequent reinforcement of the symptoms. Sedation 
as a method of cure in hospital is more doubtful. It is a very effective 
splint, like that applied to a damaged limb, but something more than 



n6 THE SHAPING OF PSYCHIATRY BY WAR 

a splint is needed; with a wounded man the broken bones must be 
set, and he may need a debridement and further active treatment. 
So, too, the best results with the war neuroses are obtained when they 
have active treatment. "Psychosurgery" in the shape of abreaction 
followed by simple re-education should as a rule precede a period 
of rest under narcosis. Hanson's group abreaction technique has 
proved exceedingly valuable and a great saving of time. In addition 
it has the great advantage of raising the group morale of patients 
who share their experiences and the discussion of those various 
problems that they all have in common. Whether this method could 
ever be used in peacetime is more doubtful; its main applicability 
seems to be with groups of men who have the factor of the army 
and war experience in common. There is, however, no question that 
the general method of abreaction followed by sedation is applicable 
to many cases in civilian life, particularly in psychosomatic condi- 
tions, and it is well worth further experiment. 

Some recent work (at Mill Hill Neurosis Centre) on the relative 
value for abreactive purposes of ordinary sedation, pentothal and 
hypnosis has provided a healthy reminder that the results of all three 
are fairly comparable and that the pentothal method is primarily of 
advantage for its speed when the doctor is overworked or for some 
resistant cases of amnesia. 

The neuroses of battle have provided us with certain opportunities. 
Those who have had to deal with them have a clearer understanding 
of psychopathological mechanisms than they would get from almost 
any other kind of work. The regimental officer, too, the ordinary 
man, has learnt more about his fellows and the way they react to 
strains and has broadened his sympathy and his understanding. As 
from the last war we learnt much about the neuroses and changed 
our attitude to the neurotic, so in this war we shall have relearnt our 
lessons and gone further in our appreciation of this major medical 
and social problem. 



CHAPTER THREE 

THE WAY AHEAD 



IN THE last chapter I mentioned the film from which the title above 
is taken. That film was written to a psychiatric prescription with a 
definite purpose. It shows how men are taken from their civilian 
individualistic occupations, and how they are gradually brought 
together by army service; they learn new skills and gradually be- 
come integrated as a group, each man playing his own specific role. 

There is much about the idea of this film which seems applicable 
to our consideration of the future of psychiatry. We cannot stand 
still and we cannot remain individualists. When peace breaks out, 
there will be more and not less need for teamwork in tackling the 
problems of communities and nations. Surely we should be discon- 
tented with our grooves, and as psychiatrists be ready for constant 
rebirth, development and adventure. 

In Great Britain we are at present somewhat concerned over the 
planning of a health service for the nation. Sir William Beveridge's 
plan suggested that there should be a comprehensive health service 
available for every man, woman and child, and in that scheme mental 
health is at least as important as physical health. Similar movements 
of thought are occurring in other countries, and few people doubt 
the necessity and the wisdom of such consideration, however un- 
certain it may be, about the best methods by which the desired goal 
can be reached. Psychiatry is the leaven in the lump, since it affects 
the larger part of social medicine, and the development, exposition 
and spread of psychiatric thought should have more to do than any- 
thing else with the success of our planning. We need to look further 
than the immediate goal of individual health; something better must 
be provided for groups as well as for individuals, for nations and 
for the community of nations. The social disorders of the world at 



ii8 THE SHAPING OF PSYCHIATRY BY WAR 

present challenge us as diagnosticians and as therapists, and in the 
postwar period our consultations must not end in words but in action 
of some effective type. 

In the preceding chapters, which are rather too much like a cata- 
logue of events, I have tried to show how the function of psychiatry 
may change as the need and emphasis vary, and new situations are 
presented. It should be made clear also that psychiatrists change, and 
that men who have come from settled routine jobs find that they grow 
very easily into a new outlook on psychiatric work once they are 
confronted with the actual necessities of the situation in the army. 
Something of the same kind will occur in our ordinary postwar 
life if we are prepared for it to happen. The urgency and intensity of 
service life may be lacking, but the problems demanding solution 
will be fully as obvious, and the opportunities will be even greater. 
The routine tasks of many psychiatrists will have to continue, for 
the sick must be cared for and research of all types must go on. There 
should, however, be few people in settled jobs who do not give part 
of their interest to the wider problems of psychiatry, and there must 
be a great many psychiatrists whose whole time is given to the in- 
vestigation and development of new possibilities. If we become more 
realistic in our attitude to our work, we may find that certain of the 
more recondite laboratory researches are excluded, but the time thus 
saved will be given to much more productive investigation of other 
problems. We cannot afford to have any good men tied solely to a 
mental-hospital job, or to a consulting-room practice in the future, 
if he has the qualities for work on a wider scale. 

The status of medicine in the community is a matter that should 
give us some thought and the status of psychiatry vis-a-vis medicine, 
and relative to the general social life of the community, is not yet what 
it might be. The profession of medicine has not altogether escaped 
from the "barber-surgeon" era, and great as is the respect of society 
for individual doctors, its estimation of the profession as a whole is 
not as high as one would wish. It is doubtful whether a whole-time 
state service, with its escape from the commercial aspects of our re- 



THE WAY AHEAD 119 

lationship to patients, would meet the situation. It seems more likely 
that far better selection of would-be doctors and an increasing empha- 
sis upon the prophylactic role of medicine would produce greater 
results. A doctor learning from inadequacy, disease and the abnormal 
should have a better contribution to make to the planning of the nor- 
mal life of society than most people, whilst from his intimate contacts 
with those who are sick or in trouble he learns, and should be the 
best possible adviser on, the manifold human problems of the day. 

The men specially trained in psychiatry have, as Doctor Salmon 
pointed out, an even greater opportunity than the profession as a 
whole to move gradually in this direction. If straightaway picked 
groups can be got together where the standards of experience and 
outlook are beyond criticism, then it should be possible, without de- 
lay, to take on wider responsibilities. We have something of value 
to say in almost every major problem of society in the planning 
and maintenance of peace, in the management of nations and their 
affairs, and in other questions of this magnitude and importance. If 
it can be demonstrated that psychiatry can produce effective help 
for group problems at every level, we shall eventually have the chance 
of helping in wider spheres. Let me make it quite clear that I am 
not claiming that we have some magic which can produce a new 
heaven and a new earth, but that I think we should be foolish not 
to recognize that our frontiers have widened, and that our particular 
skill and aptitude do enable us to make a contribution to the solu- 
tion of all problems in which human factors are involved. We cannot 
do the work of the statesmen and the economists any more than we 
can attempt to do the work of the soldier. We can, however, in many 
cases show them what the true nature of their problem is and so 
ensure that they fight on the proper battlefield. 

PLANNING FOR MENTAL HEALTH 

Having just made this excursion into the future with a tentative 
outline picture of how the functions of the psychiatrist should ex- 



120 THE SHAPING OF PSYCHIATRY BY WAR 

tend, we must ensure that our feet are on the ground, and that our 
normal day-to-day work for the community is so planned that it leads 
to real progress. Most of the British planning for a national health 
service is fairly pedestrian at the present time. This is certainly true 
of such plans as have been put on paper for the future of psychiatry. 
In part this is due to the fact that we have been planning in vacua 
since we do not know the shape of the proposals that will be officially 
made to implement the Beveridge recommendations for a compre- 
hensive medical service. The general tendency at present is to up- 
grade and link existing services, making them more efficient and 
more resourceful, and as far as it goes, this is satisfactory. The general 
line of suggestions that have been put forward in Britain is as fol- 
lows. 

The old separation between the mental hospital and the general 
hospital, between ills of the mind and those of the body, must be 
done away with. It has in the past been based largely upon the his- 
torical fact that mental hospitals of necessity provided legal custody 
for some of their patients, and the public has never quite got away 
from the prejudice against the old idea of the restrictive mental 
hospital and the asylum. The legal aspects of certification were re- 
viewed already in Great Britain in 1930, when the Mental Treatment 
Act became law, and are due for further review and simplifica- 
tion now with the advances in our understanding and the changing 
public attitude towards mental illness. We hope for legislation that 
will make it possible for people of every social group to have treat- 
ment when they need it, even though they do not wish it, without 
the necessity to invoke the law. There will be many further changes 
which should come about in the legal situation as it concerns psychotic 
and defective persons, and these are more likely to happen now than 
at any time previously. It is agreed that the mental health services are 
to be integrated with the general health service, and in itself this is 
a considerable advance which will do much to educate public opinion 
and medical opinion too. 

It will clearly not be possible to avoid all legal formalities since 



THE WAY AHEAD 121 

institutional psychiatry has to be concerned with many protracted 
long-term cases, and those who are responsible for maintaining the 
liberty of the subject must of necessity insist upon suitable safeguards. 
The emphasis, however, will be upon greater freedom in the treat- 
ment of mental cases, and a greater similarity between the mental 
hospital and the general hospital, a much closer relationship between 
the two and improved arrangements for the interchange of staff. The 
staffing of mental hospitals will need to be improved greatly. In most 
cases, there should be a 100 per cent increase in the medical staff, and 
considerable increase and improvement in the nursing staffs. The 
isolation of mental-hospital staffs must be ended, and a system of 
part-time assistant physicians, with visiting men from outside, should 
be instituted. Every member of the mental-hospital staff should have 
the opportunity of sharing in the extramural psychiatric activities, 
and this should have its obvious repercussions on the standards of 
work in the hospital and in the outpatient clinic, as well as on the 
ordinary work of the general hospital. The figures of the outpatients 
seen in the British army given in Table 3 on page 46 keep us re- 
minded of the relative insignificance of psychosis in the whole pic- 
ture of mental ill-health. Nevertheless, psychiatry is landed with this 
heavy commitment in the shape of long-term and chronic patients, 
and, unfortunately, has suffered in consequence. The public has 
thought of psychiatrists as being primarily concerned with mental- 
hospital treatment and medical schools have paid far too much 
attention to teaching on psychoses to the exclusion of the wider 
aspects of psychiatry. New emphasis must be placed on the pre- 
ventive aspects of our work, upon early treatment with all the various 
ancillary measures that are available and lastly upon the more effec- 
tive treatment and management of those who have broken down 
seriously or those who are so defective that they must be under care. 
A considerable number of recommendations along these lines has 
been formulated which should gradually be incorporated into the 
new health plans, so that mental hospitals will alter their character 
and their status, the staffing and the quality of work will be improved, 



122 THE SHAPING OF PSYCHIATRY BY WAR 

and the position of psychiatry in the general hospitals will be ad- 
vanced. The regionalization of Great Britain contemplated in the 
health plan should give the opportunity to provide sufficiently large 
regions or areas, each containing a fairly complete set of facilities 
for dealing with mental ill-health. It will probably still be necessary 
to have one thousand mental-hospital beds for each quarter of a 
million of the population, and the probable figure for bed space for 
neurotic patients in general hospitals or in special hospitals will be 
some 5 per cent of the general hospital accommodation. The neurotic 
patient must have some institutional provision made for him and 
eventually, no doubt, when mental hospitals have won a new esteem 
in the minds of the public and their medical and nursing staffs have 
a much more all-round training, the neurotic patient will be ready 
to go to the mental hospital for treatment. This already obtains in 
many instances. 

We have moved most convincingly from the lunatic asylum to 
the mental hospital, and now we must give new meaning to the 
latter. Whether we keep the name of mental hospital or speak of 
mental health centres or find some new name matters little as long 
as they are places to which patients or their relatives go with certainty 
and alacrity to get the help they need. 

On the whole, the man with neurosis is better treated as an out- 
patient and it is very desirable that he should continue his work while 
having treatment. Consequently better clinics giving more active 
treatment with far-better facilities for psychiatric social work and 
occupational placement are needed. It is visualized that the future 
development in Great Britain will throw emphasis more and more 
on to university clinics in various parts of the country which will 
function as the central point in the mental-health services, making 
close and intimate relationship with the mental hospitals, the out- 
patient service and the ancillary activities which will be provided. 

The Criminal Justice Bill which had to be shelved in 1939 is, we 
are told, likely to be brought up again at the termination of the war. 
It contemplated very considerable advances in the psychiatric care of 



THE WAY AHEAD 



123 



delinquents and psychopaths. All the various resources of the judicial 
system, the approved schools, Borstal institutions, remand and other 
special homes would have psychiatric advisers and the quality of 
work done should consequently improve. 

Child psychiatry has made considerable advances and will, with- 
out question, go much further than heretofore under the new health 
plans. This is as it should be, since it is clear that it is far more 
important to recognize and provide satisfactory treatment for ab- 
normalities of conduct or for neurotic difficulties at an early stage 
than to provide costly care and treatment in the later stages. Child 
guidance has come to be more and more under the educational au- 
thorities in Great Britain. This is partly because educationalists were 
on the whole more aware of the need for this type of help than doctors, 
and the early demands for child guidance facilities came largely from 
them, from the courts and from social agencies. Whilst the child 
guidance team of psychiatrist, psychologist and social worker has in 
theory been maintained, there has even before the war and still more 
during the war been a shortage of well-trained psychiatrists and 
adequately experienced educational psychologists, so that there is 
some danger of child guidance becoming regarded as a matter for 
the psychologist and educationalist rather than for the doctor. The 
diagnosis upon which treatment must depend necessitates a very 
wide training, and at present until we have sufficient well-trained 
clinical psychologists, the doctor is the person who is best equipped 
for diagnosis by reason of his training and background. It would 
seem wise that all disabilities, even those which appear to be purely 
educational, should be checked over by a psychiatrist, because of 
the possible physical or emotional factors which may be involved. 
It is to be hoped that all child guidance activities will eventually come 
under the National Health Service. Perhaps there may be a distinc- 
tion made between child guidance and child psychiatry, the former 
coming to be regarded more as the sorting house within the school 
system for those children who need investigation and special care, 
treatment being provided by the children's psychiatric clinic. The 



124 THE SHAPING OF PSYCHIATRY BY WAR 

name "child guidance" has certainly served a useful purpose but 
perhaps is slightly misleading since it can be argued that it is the 
function of the parent and the teacher to give guidance to children, 
while the functions of diagnosis and treatment of their disorders fall 
to the doctor. Child psychiatry holds out more hope for the mental 
health of the community than any other of the facilities so far re- 
ferred to, but yet it does not go far enough back in the scheme. We 
need the kind of investigation and care that the psychiatrist can 
provide to be available in child welfare activities and in antenatal 
clinics if we are to provide the best chances of prophylaxis in the 
mental field. Our links with the pediatrician and the obstetrician 
must be strengthened, and this is likely to come about if the plan- 
ning of a national health service works out as we hope. The problems 
of ascertainment of mental defect in children and of the special care 
and management of defectives involve a much better contact between 
the educational authorities, the general practitioners and the mental- 
deficiency experts in the public services. 

Very important problems are raised when one comes to consider 
the structure and organization of the health services it is not easy 
to plan for the organization that is going to give psychiatry its 
optimum chance of developing and coming to maximum efficiency. 
There are many arguments in favour of psychiatry and its activities 
being under some central professional direction, and yet it is difficult 
to escape from the nominally democratic control of locally elected 
committees of laymen in the various areas and districts concerned. 
The whole question is of course tied up with the structure of a 
national health service and not yet decided. The suggestion most 
likely to be put forward is that there should be in civil life a structure 
somewhat like that now obtaining in the army by which a depart- 
ment of mental health should exist, advising the chief medical officer 
centrally and having links with similar departments and advisers 
in the various regions down to the periphery. That psychiatry has 
never yet reached its proper position in medicine, there is no ques- 
tion, though its aims and its many ramifications put it in a parallel 



THE WAY AHEAD 125 

position to general medicine, surgery and obstetrics, as one of the 
four major divisions of medicine. Psychiatry infiltrates and affects 
all other aspects of medicine, and given the opportunity of developing 
technically and administratively, it will make a very material contri- 
bution. In the present state of medical knowledge, it would be a 
mistake if for the sake of an apparent integration with general medi- 
cine the development of psychiatric activity were to be placed under 
physicians who are not psychiatrists. In fifteen or twenty years' time 
that will be perfectly possible, but for the present the development 
of mental-health activities necessitates a special department, neither 
a part of clinical medicine nor of preventive medicine. Before long, 
the administrative necessities will change, and there will be no diffi- 
culties, and no claims to be made for the freedom of psychiatry. 

EDUCATION IN PSYCHIATRY 

Alongside the planning for the national health services, there has 
been a good deal of consideration given to the improvement of 
psychiatric education. Great Britain has in this respect been some- 
what behind many of the best medical schools of America, and will 
need to develop more good teachers and a greater range of educa- 
tional facilities for the future. The probability is that there will be 
much more uniform standards of psychiatric teaching as between the 
different universities and medical schools. More time will be devoted 
to the various aspects of psychiatric training during the preclinical 
and clinical years of undergraduate training. The aim of any school 
of medicine is clearly to produce doctors who as part of their skill 
have an understanding and appreciation of personality and the emo- 
tional factors in disease and can apply that knowledge wisely with 
their patients. It is clearly desirable that physicians, surgeons and all 
the specialist teachers should, whenever it is applicable, bring in the 
psychiatric aspects of medicine in their ward teaching and their 
clinical lectures. Until they are able themselves to do this, more 
responsibility will be placed on the psychiatric staff of the medical 
schools. At the very beginning of a medical student's career there 



126 THE SHAPING OF PSYCHIATRY BY WAR 

should be certain orientation lectures, some of them from the psychiat- 
ric angle, which attempt to give the student some idea of his ultimate 
aim in medicine, and to show him how some of the relatively duller 
parts of his work relate to and form a background for the more inter- 
esting and realistic work that he will be asked to undertake in the 
future. The typical immaturity of many medical students which has 
been notably lessened by the more responsible conditions under 
which medical students have worked during the war in Britain 
could be to some extent avoided by better indoctrination at the be- 
ginning of a medical career. In this way, too, from the very beginning 
a rational psychiatric approach to all his problems would be given 
to the student, and his interest drawn to the human aspects of the 
whole subject which he can watch throughout his studies. Under- 
graduate teaching will include modern realistic psychology alongside 
physiology and a growing clinical experience in the wards with out- 
patients and through lectures. The emphasis will be placed far more 
than in the past on personality and emotional disorders with their 
social implications and the appropriate methods by which they can 
be handled. There seems little need to amplify greatly the teaching 
on psychosis, though this can be linked up with the whole scheme 
of teaching and improved in many ways. 

Postgraduate teaching will most often aim at a specific training in 
psychiatry and not merely the building up of a psychiatric viewpoint. 
There has, ever since the last war, been a diploma of psychological 
medicine which has been regarded as part of the training of the special- 
ist in Great Britain. Probably this will be somewhat altered in the fu- 
ture, and it is likely that something more akin to the American plan 
will be adopted by which, after thorough experience for three years, 
with an all-round training in the psychoses, mental defect, child psy- 
chiatry and the neuroses, the candidate will take his examinations; 
thereafter he will have two years in which he may have a personal 
analysis if he wishes, can follow any special branch he chooses, and on 
the results of his work will get his diploma at the end of five years. 
This plan will certainly help to raise the standard of the consultant and 



THE WAY AHEAD 127 

specialist group, our teachers of the future, and it should be possible 
for this to foster the more progressive outlook on psychiatry, since 
it will give a man a sound all-round background in psychiatry but 
not tie him down to some one particular institution or one special 
aspect of the psychiatric field. 

On the whole, the feeling in Great Britain has been against the 
adoption of the concept of neuropsychiatry that has been used in the 
States. It is undoubtedly necessary for a psychiatrist to have a sound 
knowledge of neurology, and equally for the neurologist to be well 
trained in psychiatry, since the majority of his patients will be suffer- 
ing from emotional disorders. It is generally felt, however, that while 
there will be some common basis in the training for both subjects, 
these will be best served by separate courses of study and separate 
diplomas. There is a good deal of truth in the wisecrack that it is a 
different personality disorder which leads one man to neurology 
and another to psychiatry. There is, broadly speaking, a recognizable 
difference in the two types of men, though of course there are some 
who are equally good in both fields. 1 If we limit our concept of psy- 

1 The following quotation from a paper by E. Sapir, "Cultural Anthropology and 
Psychiatry," seems relevant. "The great difference between psychiatry and the other 
biologically defined medical disciplines is that while the latter have a definite bodily 
locus to work with and have been able to define and perfect their methods by diligent 
exploration of the limited and tangible area of observation assigned to them, psychiatry 
is apparently doomed to have no more definite locus than the total field of human 
behaviour in its more remote or less immediately organic sense. The conventional 
companionship of psychiatry and neurology seems to be little more than a declaration 
of faith by the medical profession that all human ills are, at last analysis, of organic 
ongm, and that they are, or should be, localizable in some segment, however complexly 
defined, of the physiological machine. It is an open secret, however, that the neurolo- 
gist's science is one thing and the psychiatrist's practice another. Almost in spite of 
themselves, psychiatrists have been forced to be content with an elaborate array of 
clinical pictures, with terminological problems of diagnosis, and with such thumb 
rules of clinical procedure as seem to ofTer some hope of success in the handling of 
actual cases. It is no wonder that psychiatry tends to be distrusted by its sister disci- 
plines within the field of medicine and that the psychiatrists themselves, worried by a 
largely useless medical training and secretly exasperated by their inability to apply the 
strictly biological part of their training to their peculiar problems, tend to magnify 
the importance of the biological approach in order that they may not feel that they 
have strayed away from the companionship of their more illustrious brethren. No won- 
der that the more honest and sensitive psychiatrists have come to feel that the trouble 
lies not so much in psychiatry itself as in the role which general medicine has wished 
psychiatry to play." the journal of Abnormal and Social Psychology Volume 
XXVII. Oct.-Dec. 1932. No. 3. 



I 2 8 THE SHAPING OF PSYCHIATRY BY WAR 

chiatry to the bedside or outpatient clinic, the contrast between the 
two approaches of neurology and psychiatry is not so marked as it 
would be if one's vision were wider. To discuss the problem of Ger- 
many's postwar future in terms of neurology would not be easy. 

Postgraduate training will have to be subsidized or else a sufficiency 
of resident jobs in hospitals will need to be provided to enable men 
to take the courses that are visualized. It would be a tragedy if 
specialization became the perquisite of those who had private in- 
comes and were thus able to spend the necessary time in training. 
The selection of men before they start medicine has already been 
suggested, but there will certainly be needed a further vocational 
test for those who are setting out to become specialists or consultants 
in psychiatry. While there is probably some niche to be found for 
any man in psychiatry, however shut away or eccentric his person- 
ality may be, it would seem a waste of training facilities to allow many 
men or women of this type to qualify as specialists. From the point of 
view of the community and the general progress of psychiatry, their 
contribution is likely to be much less than that made by people who 
may perhaps have slightly lower "g" but a much sounder and more 
stable personality. 

Postgraduate education in psychiatry will need to be provided for 
other groups than those who are definitely intending to specialize. 
Men whose main goal is internal medicine, pediatrics, dermatology, 
orthopaedics or any one of the many aspects of medicine will need 
special courses and facilities in getting experience in the most modern 
psychiatric approach. The general practitioner has now for many 
years demanded special short courses to orient him in the subject, 
to improve his powers of diagnosis and to help him in the effective 
handling of psychiatric problems. There will be an increased de- 
mand for this after the war and for ten or fifteen years to come, 
until undergraduate psychiatric education has made its mark on the 
profession as a whole. Even then, there will be a constant flow of 
new ideas and techniques which will need to be made available to 
everyone in medicine. If the university clinics and the postgraduate 



THE WAY AHEAD 



129 



teaching groups can be built up and can maintain a thoroughly pro- 
gressive outlook, there will be a constant demand for their services 
and their help in teaching. Since any projected state service visualizes 
refresher courses, there is no doubt that the teaching function of 
psychiatry will be amongst the most important tasks of the future. 

RESEARCH 

There has in the past been some tendency in all branches of medi- 
cine for research to be undertaken rather lightly and without suffi- 
cient relation to the real needs of the situation. It seems that on the 
continent of Europe no man can regard himself as properly launched 
on a professional career unless he has written up a certain number of 
researches, though their value may be limited and their quality very 
doubtful. To some extent, that situation also obtains in the Anglo- 
Saxon countries. In psychiatry, the mechanistic outlooks of the past 
century still colour some of the research that is undertaken in mental 
hospitals, and whilst there must without question be a continuance 
without interruption of basic research in the anatomical, physio- 
logical and biochemical fields that impinge on psychiatry, much of 
the emphasis will shift away from these in the future. If we believe 
in fact that the sociological and psychodynamic approach to psychia- 
try is productive, then we must give facilities and encouragement to 
those men who can employ their training in the study of the many 
major problems awaiting solution. For example, we want studies of 
the birth-rate problem to see how far this is in fact dependent upon 
the possession or lack of a sense of social security and the worth- 
whileness of life by men and women who are now growing into 
their positions in society. The foundations of personality and its 
disorders need profound study. What goes wrong in the earliest days 
from conception onwards and how are we to record these facts and 
how are we to remedy what at present is wrong? How can we modify 
the disturbed internal life and the disturbing external social life of 
the child as he grows up ? How can society be modified to accept and 



I 3 o THE SHAPING OF PSYCHIATRY BY WAR 

to make the optimum use of men with neurotic and psychopathic 
traits, and to avoid adding to their numbers? Here, for example, one 
has in mind the statement that the change in social structure of the 
Soviet Republics has led to a marked diminution in the amount of 
neurosis. How can the particular stresses and mental disturbances 
that lead to psychosomatic illness or to social unrest be identified 
and changed? What is to be learned from the more careful study of 
interpersonal relationships, the development of the life of communi- 
ties, and how can these be better planned so that instinctive tendencies 
can be profitably used and cultivated in order to avoid major diffi- 
culties such as international clashes which lead to war? How are 
the psychopaths and the antisocial elements in modern civilization 
to be better understood and better dealt with? These are just a very 
few of the problems which occur to anyone who looks round in the 
psychiatric field as being of major importance. In research as in every 
other branch of our work, we must think in terms of priorities, and 
if we can produce the men and women capable of tackling these 
problems, they will in many cases be more profitably employed than 
in test-tube and microscope research. "Without vision, the people 
perish," and we must arrange as we look ahead that our young men 
see visions that are extensive and not merely intensive, whether in 
the laboratory, in psychopathology or in sociology. 

WIDER FIELDS 

As our vision ranges over the problems which challenge us, we 
pass from the reorganization and revitalization of our existing 
psychiatric activities to wider aspects of the subject, for clearly we 
must look further and go further afield than we have yet been. 
Psychiatry cannot and should not attempt to take on tasks other than 
its own, but it must aim deliberately at cross-fertilization in every 
field in medicine and the health services. There is no sharp dividing 
line between psychiatry and any other branch of medicine nor indeed 
between psychiatry and any other branch of knowledge that concerns 



THE WAY AHEAD 131 

human beings and their welfare. Psychiatric thought must become 
part of the ordinary approach to his tasks of every worker in the 
field of health and human relations. This penetration must not be 
regarded as the function merely of specialized research units, im- 
portant though these are; it should be thought of as part of the task 
of every man or woman who has acquired a psychiatric outlook. Upon 
our work and our attitude depends the speed with which the human 
factors will be recognized and understood by sociologists, politicians 
and statesmen the world over. For most of us this will mean a much 
closer co-operation with local groups of varying types whom we can 
contact, but there is no unit so small that it is not worth study and 
no community that will not repay effort and experiment. Advances 
in human affairs come far more often from the workers on the 
periphery than from those who arc centrally placed. New ideas which 
are valid in their application are as likely to come from the outlying 
workers in psychiatry and medicine as from the high-powered re- 
search teams. 

DO WE NEED A NEW IDEOLOGY? 

Hitching one's wagon to a star need never be an alarming affair 
provided that we retain some contact with solid ground. We never 
reach the star but we do get a little nearer to new things in this way, 
and only in this way. Psychiatrists are specialists in mental health. 
They should not limit themselves to mental illness as they necessarily 
did in the old days. In consequence, as has been argued above, psy- 
chiatry must be planning in a strategic manner for the mental health 
of the future. We cannot ofTer scientific advice on treatment unless 
we have made a reasonably accurate diagnosis and that must clearly 
be our first attempt, though it will be only partially successful when 
we are dealing with the larger problems of society. The disorders of 
groups, communities and nations have so many aetiological factors 
that we can only work in with the many other groups who are 
tackling these problems, add our contribution to diagnosis and then 



I 3 2 THE SHAPING OF PSYCHIATRY BY WAR 

help to suggest the remedial action. We know from experience with 
individual patients that we can understand the nature of their prob- 
lems, that we can prescribe treatment and that when we follow out 
that plan, results materialize. We know from our experience of 
groups under more or less controlled conditions, as in the services, 
that the same procedure can be followed with similar results. It clearly 
does pay to give a correct prescription for social planning as for 
individual direction. 

Many people who are free to express their beliefs would at the 
present time be in favour of compulsory service in the armed forces 
or under controlled industrial conditions for all young people, and 
there are great advantages in such a plan, which the war has made 
obvious. For the individual who has passed school age and is starting 
out on life, the services should be able in peacetime to offer all the 
advantages they have in war without the disadvantages. The assess- 
ment of physical health and ill-health with special physical develop- 
ment centres and remedial techniques of all kinds would be available. 
Those men or women whose emotional development had in some 
way gone astray would under controlled conditions be more wisely 
handled than is usually possible in civil life. The psychopath and 
the delinquent would have an opportunity of readjustment and re- 
socialization under ideal conditions. It is not merely those whom at 
present we tend to regard as coming from the psychopathic tenth of 
the population who would benefit the more normal individuals 
would also get the benefits of community life, all the advantages for 
a short time of a good college existence, and it should be a transition 
between school and industry to which they pass, knowing their best 
vocational choices and so with a line on their activities. They should 
also pass out having some degree of training for their specific occu- 
pations in the future. From the point of view of the community these 
groups would give unparalleled opportunity for experiment and re- 
search into the methods by which individuals and groups can be 
handled. The normal could be studied, which matters more than the 
abnormal, and a greater degree of national maturity would result 



THE WAY AHEAD 



133 



whilst it should be quite possible to guard against undue uniformity 
or suppression of individual trends. 

This, however, is a reflection on what may never happen, though 
there will be in any case for some years large groups of service men 
and women who should be able to be helped and at the same time 
provide the material for forwarding the general development of 
society. It, to mention only one point, we could employ our dullards 
in service labour corps, where we could provide ideal conditions for 
them, they would in most cases wish to stay on. Both they and so- 
ciety would thereby benefit. 

If we propose to come out into the open and to attack the social 
and national problems of our day, then we must have shock troops 
and these cannot be provided by psychiatry based wholly on institu- 
tions. We must have mobile teams of well-selected, well-trained 
psychiatrists, who are free to move around and make contacts with 
the local situation in their particular area. There can be interchange 
of these men with those who are working in hospitals and research 
centres, but their primary loyalty should be to the common weal 
rather than to some one particular institution or local part of the 
service. The schemes of divisional, corps and area psychiatrists in 
the services have proved how effectively this job can be done. These 
men are responsible for the mental health of their particular forma- 
tion, and they are interested and concerned with a very large variety 
of things which may happen within that formation and they should 
know and be known by the majority of people in their area. They 
are not merely dealing with outpatient work amongst those who fall 
sick, but they are also concerned with the minor indications of insta- 
bility that link up with disciplinary troubles, with social unrest and 
with poor morale. Through their emphasis on, and interest in, con- 
ditions of work, they can advise on the modification of working hours 
and conditions, on welfare and the use of leisure, on training and 
allocation and on all the manifold group problems that are there to be 
seen by anyone who is in the group but yet has learned to be detached. 

Effective group therapy conducted by someone with a sound train- 



'34 



THE SHAPING OF PSYCHIATRY BY WAR 



ing in analytic methods provides a very good illustration of what 
can be done in the still larger group to bring about better mental 
health. If there are to be state services, then it is important that we 
should not forget to plan for psychiatric teams for this type of work. 
It is not a waste of a man's training to take a good and experienced 
clinician and therapist and put him on to work of this kind. Just as 
short methods of therapy are best carried out by those who have 
training in the prolonged methods, so the same principle operates 
here, and the most effective work in groups is done by those who 
have a good understanding of the handling of individual problems. 

If there is this "cutting edge" of psychiatry, then there will be a 
great flow of problems coming in for solution. Procedures, tests and 
techniques will need to be worked out, validated and compared and 
for this there will have to be research groups in each area, centres 
where men have time to think, and where there is an adequate staff. 
Psychologists, sociologists, those with a sound knowledge of biology 
and certainly statisticians will form part of these groups, and they 
will need to make contacts with similar groups working in other 
areas and on parallel or divergent problems. 

Financial endowments from voluntary sources and the support of 
the great foundations have in the past been given to efforts along 
these lines. They will still be needed and there will be far greater 
scope in the future for constructive work to be done by such funds. It 
is to be doubted, however, whether this is sufficient. It does seem as 
though there would have to be state support for work of this type, 
and it will be necessary to tackle, as one of the sociological and psy- 
chiatric problems, the structure and relationship of such units to 
ensure that they provide for freedom of scientific and technical 
thought while yet acting as servants of the state. 

Many references have been made in the past to the relatively in- 
sufficient sums of money spent by official bodies and governments 
on research, whether in psychiatry or other fields, and that is cer- 
tainly a point upon which conviction must be built up without delay. 
The total annual cost of the comprehensive psychiatric services of 



THE WAY AHEAD 135 

the British army equals the cost of the British contribution to running 
the war for an hour and twenty minutes. It should not be so difficult 
after the war to convince governments that funds made available 
for progressive, scientific and health activities will pay a positive 
dividend and much of it quite quickly. 

A great advantage of the mental-health service, particularly its re- 
search and advisory centres, being related to the government is that 
they have a much better chance of being consulted on questions of 
higher policy. Just as material from the periphery will flow in for 
checking, validation and advice, so requests for help and advice 
should come to these bodies the more they accumulate experience and 
knowledge. In this way psychiatry would seem to have its best chance 
of trying to make some contribution to the bigger problems and 
policies of a country. Progress on this side of our activities will neces- 
sarily be slow. As I said previously, the status of psychiatry can only 
be built up as it shows that it can produce results and that it does not 
oversell itself. We can even now give some help to all those who are 
planning for postwar problems, and without any question we shall 
be asked increasingly to help. Industry, which touches the life of the 
great majority of the community, will certainly need help. Men who 
are being demobilized will go back to fresh units which must provide 
conditions as good as and better than those provided in the fighting 
services or in wartime industry. The future of industrial psychology 
and of industrial psychiatry will need to be watched over very care- 
fully if high standards are to be maintained, wise advice to be given 
and generally progressive, non-cranky methods supported. 

Educational planning is moving forward and again this is not our 
responsibility, but it is our privilege to be able to help with many of 
the vital points in such schemes. The most enlightened administrators 
of educational policy are liable to overlook the fundamental human 
and dynamic factors involved in their schemes, and the psychiatrist 
can help here. The whole series of unsolved problems with regard 
to delinquency, its early recognition and cure, to the management of 
varying groups of antisocial persons, once their abnormality has 



136 THE SHAPING OF PSYCHIATRY BY WAR 

shown itself, and to the question of their social reintegration are prob- 
lems that demand an immense amount of careful enquiry and assess- 
ment and experiment. On every side of our social life, our employ- 
ment of leisure, the situations that go to create and maintain home 
life, the care and responsibility of orphans or children separated from 
their homes (a matter which at the moment is being very fully 
ventilated in Great Britain) are typical instances of the large-scale 
problems to which psychiatry, starting from the experience and 
understanding of individuals, can learn to contribute many things of 
real value. We shall find ourselves after the war faced with a mael- 
strom of problems, social discontents following demobilization and 
resettlement, the necessity to deal with large numbers of awkward 
individuals, and many other situations which have their political 
and economic aspects markedly to the fore. The postwar malcontents 
may well be written down as having been infected by subversive in- 
fluence, as communists or whatnot, unless we are able to demonstrate 
that in fact they are men who have been unwisely handled and who 
are reacting like rebellious and difficult children. The solution is 
likely to lie more along the lines of social psychiatry than of official 
suppression. We shall get further experience from our failures and 
successes in the handling of these problems to help us understand 
that big problem of international unrest and struggle which is so 
much in our minds at present. Some years before the war a group of 
Dutch psychiatrists made an appeal for the study of the aetiology 
and prevention of war. That apparently met with little success, partly 
because psychiatrists as a whole were too occupied with problems 
they believed to have a prior claim on their time, partly because the 
plan was rather too much in the air, and largely because few of us 
had an ideology with regard to our profession which led us to 
accept the social responsibility of trying to contribute on this major 
issue. 

If at first we are not asked into the councils of those who are at- 
tempting to re-establish the world, it will not be surprising, but we 
can at least utilize our experience and begin to make our diagnoses, 



THE WAY AHEAD 137 

formulate prescriptions and implement these prescriptions in well- 
chosen situations. There is no state department in the democratic 
countries of the world that will not take notice of suggestions that 
are well and scientifically based, proven and documented, for the 
world of affairs is very much more alive now than in 1939 to the fact 
that irrational emotions can sway whole countries as well as indi- 
viduals, and that clearer understanding of one's neighbour is essential 
if one is to help him in the settlement of his affairs. It would seem 
that we have in the future a chance of learning to give advice on 
these bigger problems. The almost defeatist attitude of those who 
can only think of progress in terms of the most complicated changes 
in individuals must give way to planning for groups. Individual 
upbringing will only be modified through the passage of time. A 
psychoanalytic type of management, adapted to each particular racial 
culture and demanding individual change as the basis of progress, 
involves us in a rather hopeless quagmire, but by the broader applica- 
tion of analytic understanding, we can devise approaches to the 
problem which are far more hopeful. The social alterations that can 
be brought about will produce internal and individual change, though 
they may not be as far-reaching as we desire. Yet they still will pro- 
duce a more hopeful and a more progressive world. That surely must 
be one of our aims. In every country there should be groups of 
psychiatrists linked to each other, studying these problems in as 
realistic and practical a fashion as possible. Much of the experience 
of war conditions can be made use of, and within our own national 
structure or in our contacts with liberated and occupied countries, 
there are facilities in plenty for the necessary experimentation and 
validation of ideas. As far as I am aware, UNRRA has yet no ad- 
visory body from the psychiatric angle. With the cessation of war we 
shall be liable to drop into sentimental rather than realistic thinking. 
Whether we treat Germany and Japan kindly or roughly is as ir- 
relevant and unimportant as whether we treat the individual neurotic 
in either of these ways. What matters is that we should understand 
the people, their make-up, their culture and their social setting, and 



138 THE SHAPING OF PSYCHIATRY BY WAR 

that we shall devise methods by which these can be modified to the 
advantage of the world as well as themselves. 

Turning once more to our home problems, it has been pointed out 
that there is some danger inherent in this weapon of selection that 
is available as a technique for social medicine. It could be used arbi- 
trarily and wrongly from a socio-political angle, just as it could very 
easily become a racket if it fell out of scientific control and manage- 
ment. A great danger today comes perhaps from the fascist tendencies 
which exist in our own countries as amongst our enemies. The 
Wehrmacht has, it is understood, given up the whole of its elaborate 
scheme of selection, despite the marked success that it was reputed 
to have had. Presumably the Nazi Party in Germany could no longer 
stand for a method which kept party men out of good jobs through 
the effort to put the best men into the jobs for which they were best 
suited. That may easily happen in other countries also, and only the 
keen watchfulness that we amongst others can keep on the tendencies 
that show themselves in our national life can control situations of that 
sort. It is an illustration of the need for democracy, and to the princi- 
ples of democracy we among many others have our quota to add. 
If we can help find the right leaders, if we can make more channels 
upward and ensure that they carry the right personnel, then our in- 
ternal problems and our international relations alike will show a 
response to psychiatric thought and effort. 

IN CONCLUSION 

Finally, if people think that this is the time to widen our horizon, 
to increase our activities and to alter some of the emphasis that we 
have placed on various aspects of our work, we shall certainly have 
internal as well as external difficulties. Scientifically as well as eco- 
nomically there are "the old men" to be dealt with. There are the 
vested interests of psychiatry to be met. We are too much dominated 
by clinical interest, by the burden of the psychoses and by local gov- 
ernment. If we are sufficiently enthusiastic and are prepared to select 



THE WAY AHEAD 139 

ourselves, we can fight through these various obstacles and, improv- 
ing all that now exists, we can add to our work new and more 
profitable projects, some of which are touched upon in these chapters. 
There can be, in fact, no conclusion; there really is no end to our 
task, for all the time we shall find ourselves coming afresh to the be- 
ginning. 



APPENDIX 

THE TASKS OF PSYCHIATRY 



THIS appendix constitutes a summary of many of the points that 
have been raised in the chapters of this book. It seems well that we 
should list some of the tasks which psychiatrists in the armed forces 
of various countries have been undertaking, so as to see how much 
these projects suggest similar needs or possibilities in civilian life. 
The list which follows is not comprehensive but singles out some 
of the more obvious aspects of work in the services. It will be clear 
that many of these are already better done in civilian life than they 
ever could be in the army. Others had been inadequately stressed 
before the war, and it will do no harm to set ourselves thinking about 
their possible development in the future. As civilian psychiatrists, we 
will still have a responsibility for helping and advising in the main- 
tenance and development of military techniques, while at the same 
time it will obviously be necessary to think of modifications of these 
procedures to meet civilian needs. What matters is that any principles 
that seem of proven value should be considered and possibly inte- 
grated into our postwar work. 

Most of us could make additional lists and it is to be hoped that 
we will do so. We must give all encouragement to every psychiatrist 
and every group of psychiatrists to progress along their own par- 
ticular line, experimenting and finding their own solutions for the 
particular problems that crop up. It is much to be desired that all 
psychiatrists should have the opportunity of being members of a 
group and that each group should have a session of "progress chas- 
ing/' say every six or twelve months. Progress reports are vital in 
all successful production mechanisms, and we have not had enough 
of these in our work heretofore. 

We must see to it that more jobs, with real scope, are available for 
psychiatrists. 



APPENDIX I 4I 

It may be worth while for us to stimulate in some way the younger 
men, and ourselves too, to more realistic ideas which will force us 
to find advances both in therapeutic and social psychiatry. The cinema 
world awards its golden statuettes for meritorious performances of 
various kinds. Nobel prizes are awarded in a very different field; 
possibly psychiatry might do well to offer some such recognition for 
effort and initiative, though clearly the main driving force will always 
be our interest in humanity and our scientific concern. 

PSYCHIATRY IN THE ARMY * 

1. AREA PSYCHIATRY 

This involves outpatient consultations both at clinics and in units. 
A great advantage of the latter is that it is possible for psychiatrists 
to obtain an assessment of the man's value to his unit and careful 
reports from those who live with and work with the man. The visits 
to units which arise from this need to see patients are of great value 
since they lead to discussions about unit morale, disciplinary ques- 
tions, etc. The assessment of morale and the help in education in man 
management which can be given through personal contacts are very 
valuable. 

Help in selection procedures which involves close working in with 
the psychologists is an important part of area work, while the follow- 
ing up of men through the various stages of their training to ensure 
that they are properly placed aand adequately handled is important. 
Many special tasks come the way of the area psychiatrist, problems 
of groups taking on new or difficult jobs, special cases of various kinds 
which need well-thought-out disposal. The job of the area psychiatrist 
is to be responsible for anything and everything that benefits the 
mental health of the area in which he works. 

2. SELECTION PROCEDURES 

These all involve close co-operation with industrial psychologists 
and may be regarded as of fundamental importance in military medi- 

* For counterparts in civil life, see pp. 147-154. 



142 THE SHAPING OF PSYCHIATRY BY WAR 

cine. The psychiatrist sees all those who are referred to him by the 
psychologist, i.e. those of low intelligence, those of higher intelligence 
who are unstable and all the doubtfuls; he also refers back to the 
psychologist many cases for help in assessment and placing. The 
psychiatrist has to create and maintain an atmosphere in which the 
psychologist can make good clinical judgments in so far as he needs 
to do this, and he has also to ensure that the unit medical officer and 
general medicine as a whole is kept in contact with the selection 
procedures. The main forms which selection takes are: 

(a) Posting and allocation of men on coming into the services. 
There is a complete job analysis to facilitate the correct placing of 
men. There are many who because of mental limitations and special 
personality difficulties demand particular consideration if they are 
to give good service and find themselves as square pegs allocated 
to square holes. 

(b) Re-selection. This is necessary for those who are misfits who 
may have been improperly placed at the beginning by some accident, 
or there may have been some physical or mental deterioration which 
necessitates recheck and fresh assignment. This applies to both men 
and officers. 

(c) The placing and arrangements for proper care of the dullard 
form an especially important part of selection procedure. It is vital 
that he should be got into his proper niche where he can give good 
service. 

(d) The man of very high-grade intelligence is often an equally 
great problem since there are a limited number of jobs and special 
types of employment where the intelligent man with indifferent 
stability can be properly used. 

(e) Neurotic men. Those who are constitutionally predisposed 
may need treatment, or they may be dealt with more satisfactorily 
by the sociological technique of correct environment and occupation. 
These are all individual problems which need the most careful assess- 
ment. 

(/) Special jobs demand special selection techniques, and in al- 



APPENDIX 143 

most every case the matter becomes more one for the psychiatrist 
than for the psychologist unless he has had special clinical training. 
These include particularly difficult and stressful employments, such as 
jobs involving a high degree of concentration and at the same time a 
high degree of security; parachutists who have a skilled and at the 
same time an extra dangerous role; psychological warfare, which 
demands men of differing qualifications with varying degrees of 
stability and special qualities of character and personality. 

3. SPECIALIST SELECTION 

The emphasis on character, personality and stability which has 
led to the development of special methods of selecting officers in the 
British army has called for psychiatric help. Psychiatrists devised this 
scheme and have been responsible in the main for its development, 
while there has been an increasing contribution from clinically trained 
psychologists. There have been a number of derivatives from the 
original work such as the selection of women officers, whose function 
is different from that of men officers, of regular officers where long- 
term development of character has to be considered. Other fighting 
services have asked for help and have brought a series of fresh re- 
quirements and fresh problems. Psychological warfare workers with 
their varying qualities for many types of work have been selected, 
as also have those who are to work in civil affairs and later in over- 
seas civil administration. Fire service workers, civil servants and 
school boys for university grants and training have all been selected 
by varying techniques based on the common principles referred to in 
this book. 

4. FOLLOW-UP 

It is probably true that the follow-up procedures in the army have 
been more thorough than in the majority of groups in civil life. Not 
only the effect of treatment on patients has been followed up but the 
results of special employment and the effectiveness of various dis- 
posal mechanisms have been validated. The follow-up of selection 
procedures and especially of officer selection has been and is being 



I4 4 THE SHAPING OF PSYCHIATRY BY WAR 

carried out with the greatest scientific accuracy. A great deal of 
knowledge has been accumulated as to the uses, possibilities and 
limitations of questionnaires and interview techniques. This is of 
the greatest value in checking and validating many of the army's 
procedures and it should prove a great store of factual knowledge 
which will be of use in peacetime. 

5. EDUCATION 

The army has undertaken, as much as it can, the psychiatric edu- 
cation of medical officers though this has been very inadequate. At- 
tempts have been made to give general orientation lectures on psy- 
chiatry to all medical officers. Groups of lectures and short courses 
have been provided for specialist physicians and others. Courses of 
three or six months' duration have been provided for the rapid train- 
ing of those who had some slight bowing acquaintance with psychia- 
try beforehand, but of necessity all these have been rather superficial. 
Much teaching of the regimental officer has been undertaken through 
army schools, officer cadet training units and in various active for- 
mations. This has been, much of it, on the lines of simple mental 
hygiene as the larger part of man management, and in part it has 
had specific reference to the recognition and better management of 
battle neurosis. Special groups such as chaplains, welfare officers and 
educational officers have had some instruction. 

6. TRAINING 

Psychiatrists in the army have recognized the importance of sound 
training as one of the facets of morale, and consequently have spent 
some time in trying to help with the development of more satisfactory 
and adequate methods. Recently psychologists have quite properly 
gone further into this field, and considerable advances are being made 
in the application of sound educational methods. Grouping by intelli- 
gence has proved its value in army training. The selection by intelli- 
gence and by the personality of illiterates for training has for army 
purposes proved valuable. Methods such as that of battle inoculation 
have been introduced alongside collective training, with the idea not 



APPENDIX 145 

only of improving efficiency but also of safeguarding men from undue 
(because unfamiliar) stress once they get into battle. The value of dis- 
cussion groups run in the army by the Education Corps and the Army 
Bureau of Current Affairs has been demonstrated as an aid to better 
mental health. This is something that has great value. The art of teach- 
ing by films has advanced largely because a good deal of thought has 
been given to the emotional reaction produced by the film, instead 
of merely concentrating on the technical efficiency of the production. 

7. SPECIAL INVESTIGATIONS 

Many opportunities arise in service life to carry out enquiry into 
the nature of the difficulties that produce or predispose to various 
disabilities and to the type of personality involved. Some of these 
enquiries can be mentioned: 

(a) What sort of men get venereal disease and why? 

() Refusals amon^ parachutists. Here a considerable number of 
complex issues had to be studied which involved the study of the men 
themselves and the various circumstances which were capable of 
modification. 

(c) Mass neurosis. There have been a few instances which have 
been carefully studied where symptoms of acute neurosis (one case 
appearing as an outbreak of religious emotionalism) have made 
their appearance. As would be expected, the position, structure and 
leadership of the group have been at fault as well as the individuals 
concerned. 

(d) Desertion and similar crimes. These have been studied care- 
fully in many individual instances, and on one or two occasions when 
a group has been affected in this way. As may be imagined, the 
fault does not always lie with the individuals concerned "shooting 
is all right, provided you shoot the right person/' 

8. SOCIOLOGICAL TECHNIQUES 

(a) Opinion surveys. These have been carried out in many cases 
with a view to assessing morale and for administrative purposes. It 
has been very clear that both in the drawing up of the questions and 



146 THE SHAPING OF PSYCHIATRY BY WAR 

still more in the evaluation of the situation, a psychiatrist with a sound 
analytical experience is able to add meaning to these studies which 
nothing else can supply. 

(b) Sociomctric experiments. Although these have not gone as far 
as was hoped, a number of experiments with group choice, e.g. the 
selection of their own potential leaders by the group, have been made. 
Such experiments, however democratic they may be, have to be 
handled rather carefully within the structure of the army, though 
they have great value. 

(c) Delinquency. Experiments made in the classification of delin- 
quents of various types and with differing prognoses have been en- 
couraging. One thing which has emerged very clearly is the need for 
very special selection and for more careful training for those who 
have to deal with this type of man. 

(d) Returned prisoner-of-war problems. These have been studied 
very closely and the findings have bearing also on the problems of 
demobilization and the questions of displaced communities. Apart 
from those who actually break down and need treatment, there is a 
large group of men who need very careful understanding if their 
resocialization is to be satisfactorily achieved. 

9. MORALE 

Much time has been given to the study of problems in this con- 
nection in the army, and in a large measure the work is psychiatric. 
The devising of indices and methods of assessment of morale, advice 
as to methods for changing the situation, either indirectly or through 
direct administrative procedures, the use of the radio and films all 
provide methods of attack on certain problems. Morale committees 
have shown their value in serving as collecting points for a large 
amount of material and for the education of those who have to im- 
plement the administrative recommendations. 

10. REHABILITATION 

A number of experiments and investigations have been made and 
still are in progress. It is hoped that something rather more definite 



APPENDIX 147 

will emerge as to the scientific bases of rehabilitation, so that the gen- 
eral principles for the training of the medical profession and its 
ancillaries for this work after the war will be better directed. There 
has been a move away from the old standard ideas of occupational 
therapy, so far as ambulant cases are concerned, towards more active 
and practical types of occupation. Studies have been made of the per- 
sonality difficulties and problems of resettlement of the blind, the 
partially sighted and the limbless. Reconditioning and rehabilitation 
work of various types in the services has been studied, and it has 
emerged clearly that one of the major factors in achieving good re- 
sults is the individual care and welfare work provided, which build 
up good individual morale and so predispose to speedy recovery. 

n. PSYCHOLOGICAL WARFARE 

A considerable psychiatric contribution has been made in this rela- 
tively new field during the war. Not only the selection of men for 
the various types of work, which is certainly a matter of importance, 
but also the design of some of the principles upon which they work 
have been shaped by psychiatric thought. Careful analytic studies have 
helped in the devising of propaganda, and in advice upon the various 
aspects of military policy. Surveys in occupied countries and else- 
where have provided a great deal of the material which, with psychiat- 
ric evaluation, has been used in the planning not only of present but 
of future activities and postwar situations as well. 

PSYCHIATRY IN CIVIL LIFE 

I. Whatever they may be called, there would seem to be a place for 
psychiatrists to be responsible for the mental health of every area or 
region. It may be tentatively suggested that one such psychiatrist, 
additional to all institutional and clinic facilities, should be provided 
for every 50,000 to 75,000 of the population. These men should be in 
whole-time service, so that there is no splitting of their interest and 
loyalty. They should always be men with good all-round psychiatric 
training and they may later on find some more static job to which they 



148 THE SHAPING OF PSYCHIATRY BY WAR 

will certainly bring a great accumulation of experience and interest. 
Probably each appointment of a psychiatrist in any particular area 
should be limited to a period of three years, which could, if necessary, 
be renewed. This would ensure the maintenance of live interest in 
the psychiatrist and would make it easier to replace one who was not 
quite keeping up to the job. Their work would consist of looking after 
outpatients or helping with outpatient clinics where necessary, domi- 
ciliary visiting, contacting schools and industrial firms, and many other 
activities in their area. They might take over the ascertainment of 
defective children, and would be advisers to the responsible adminis- 
trative officers of the mental-health services and the general health 
service in that area. They should have close contact with all psychia- 
trists, whatever their job, who are working in that region, and a very 
intimate team relationship with other men doing the same work in 
neighbouring areas. The interchange of experience and ideas gained 
by regular group meetings is of great value. 

2. Job analysis is no new concept to industry. Little work has up to 
date, however, been done towards complete analysis and evaluation 
of all the jobs that are necessary and available in the industry of a 
country. Better selection is certainly going to help to maintain good 
health and efficiency, though it will probably be best carried out on a 
voluntary basis so that there shall be no undue sense of regimentation. 
There are two main dangers to be foreseen firstly, that selection will 
be undertaken by people with very limited knowledge who will set 
up as personnel consultants unless there be some central machinery 
for regulating and approving such work. There might be an official 
body under the Labour Ministry which can lay down the standards 
of training, maintain the level of proficiency, and approve the various 
activities that are undertaken. Secondly the danger is that individual 
wealthy firms will set up their own machinery for selection, thereby 
taking the cream of an industrial population in an area, leaving the 
less apt to work in the smaller firms. Population groups varying from 
say 100,000 to 200,000 would seem to be the ideal for the incorporation 
of selection procedures since many kinds of industries are likely to 



APPENDIX 149 

be represented, capable of giving proper employment to all the avail- 
able workers in that area. 

The importance of placing dull people has already been stressed. 
If conscription were maintained and these men on coming into the 
army were picked out and properly employed many of them would 
choose to stay on in labour companies where they would cease to 
create a social-problem group, and we should make some advance 
towards the solution of the problem of inherited mental deficiency. 
Similarly dull women could well be recommended for training for 
suitable domestic and other work. The problem of household help 
may in the future be met by the organization of women into groups 
or a "service." The domestic service situation has in the past been 
increasingly difficult, but the cause has been the "problem employer" 
with her lack of understanding "bad officers make bad soldiers." 

The proper employment and handling of groups of neurotic men 
and women in industry, when they cannot reasonably be expected to 
be cured, is a matter of high social importance. New techniques need 
to be devised for the medical and social care of such groups, and in- 
efficiency could be checked in this way. There are many special tasks 
demanded of industry and some of these are dangerous occupations 
very comparable to that of the parachuting infantry. Coal miners and 
transport workers, divers and caisson workers suggest the types of 
employment. Many of the occupational neuroses and much industrial 
wastage could be cut down by better selection and better care of the 
working methods and management of these groups. Voluntary voca- 
tional guidance centres in every area would provide the opportunity 
for dealing with those who are misfits, whether by personality or 
following illness. An important part of rehabilitation after any serious 
illness is that the man should be properly and adequately employed, 
and this may involve changes of occupation that should not be left 
to chance. Too many men have in the past taken to a career of chronic 
drifting after some illness that made them unsuitable for their par- 
ticular original job. It is very important that medicine as a whole 
should be more in the picture as regards selection. And it is not 



I 5 o THE SHAPING OF PSYCHIATRY BY WAR 

merely the psychiatric cases that need the help of selection procedures, 
but also a very high proportion of men and women with physical 
disabilities and those who are recovering from long-term illnesses. 
Correct employment is something that needs more than the advice 
of the hospital social worker, and should come to be regarded as an 
essential part of treatment provided by the allied service of indus- 
trial psychology. 

3. In civil life, specialist selection is more complex but more neces- 
sary. Certain professions spring to mind straightaway as deserving 
much careful experiment and work in devising special techniques for 
the choice of their trainees. Teaching, the law, the church, the civil 
service, politics, and our own profession of medicine are good ex- 
amples. A recent article in the centennial American Journal of Psy- 
chiatry has stressed the fact that selection of men and women in 
industry for the more responsible positions is best carried out by 
psychiatric aid, which confirms the experience that has been accumu- 
lating from many other sources. The deans of universities and other 
colleges are in many cases less happy than they should be about the 
quality of their students, and they are ready for the introduction of 
improved methods. The importance of such better selection is that 
not only will there be greater efficiency in these various occupations, 
but there will be fewer disappointed and disillusioned men tending 
to regard themselves as failures and to drift from job to job. It is a 
legitimate phantasy that a truly democratic country may in the future 
choose its legislators on grounds of personality and character instead 
of selecting them for those reasons that now obtain. Our present 
methods of selection for this important work of government can 
hardly be said to be altogether satisfactory. 

4. In many ways, the medical profession whether in specialist prac- 
tice or in general practice has had a lamentable lack of accurate 
knowledge of the results of its work. Wishful thinking and a 
variety of circumstances, such as the ease with which patients can 
move in civil life from one doctor to another or from one hospital 
to another, have led to much wastage of effort and material. Our 



APPENDIX 151 

techniques for obtaining scientifically controlled studies of the later 
history of patients and of groups needs to be improved, and when we 
do this a new realism will be introduced into our therapy. 

5. Our facilities for education in civil life and our achievement 
there are, of course, far ahead of those in the army, but one or two 
points emerge which may be of some importance for the future. The 
experience of most armies has shown that forward psychiatry, which 
is comparable to the peacetime first aid of psychiatric breakdown, can 
often be done as well or even better by the general physician with 
good regimental experience than by the specialist psychiatrist. The 
latter is of course essential for the treatment of more serious cases 
which must be hospitalized for a while. The medical officer of the 
regiment or field ambulance forms a part of the patient's actual en- 
vironment he talks the same language, he shares the same experi- 
ences, and, provided that he has a reasonable grasp of the mechanisms 
that are at work leading to the development of acute neurotic diffi- 
culty, he is particularly well suited to the management of it in the 
forward stage, and his results from the point of view of the army 
have been extremely good. This seems therefore to emphasize the 
importance of postgraduate education, short refresher courses and 
very practical teaching based on the day-to-day problems of the com- 
munity for general practitioners and all those in contact with patients 
in their homes and in industry. Provided that this teaching can be 
sufficiently realistic there will be no difficulty due to unwillingness 
on the part of the doctors to ask for it. The psychiatrist, too, needs a 
practical and realistic education. Our hospital and consulting-room 
techniques are by themselves inadequate for dealing with the ills of 
society. We need to get into homes and into the industries where men 
work and to learn their point of view and their language. We shall 
in the future have to assure ourselves more and more that there is a 
sounder foundation in specialist psychiatric education especially on 
the psychodynamic side, which will enable these specialists to under- 
take short methods of treatment, group methods and the sociological 
approaches to ill-health and its prophylaxis. 



1 52 THE SHAPING OF PSYCHIATRY BY WAR 

6. Educational procedures, good or bad, affect mental health for 
good or ill, and consequently education must be the interest of the 
psychiatrist, and he has an increasing contribution to make to the 
development of educational techniques. Adult education will need 
more emphasis, and it is important that in industry there shall be 
better training for all the jobs which are allocated to men and women. 
To have pride in one's technical skill is so important that there must 
be good efficient training for every job, however simple it is. This is 
not merely a question for the production engineers; it is a matter 
that affects those of us who are responsible for the mental health of 
these units. The introduction of discussion groups into industry 
provides something that is akin to group therapy, and it can be a 
very effective prophylaxis against unrest and the development of 
neurotic reactions. Much depends upon how these groups are con- 
ducted, and that demands a good deal of thought and study, and a 
considerable contribution from our side as psychiatrists if full use is 
to be made of this method. Effective and purposeful training is as 
necessary in every industry or business as it is for the professions and 
if it can be provided it will certainly make a contribution to our future 
social medicine. 

7. (a) These personality investigations have very obvious impor- 
tance in civil life, and especially there should be a parallel study of 
the situation as it affects women. There are so many emotional and 
sociological factors at work that it is essential to have more knowledge 
for the better design of educational and prophylactic measures. 

(b) Coal mining and other dangerous occupations provide situa- 
tions which are very similar and which can without doubt be solved 
the better by some clearer understanding. 

(c) Political groups, subversive movements and many other socio- 
logical phenomena lend themselves to such study, and it is a matter 
of great importance that they should be properly understood from 
a psychopathological and social angle if they are to be correctly 
handled. 



THE WAY AHEAD 



'53 



(d) The problems of absenteeism and strikes must provide very 
similar material capable of similar handling. 

8. (a) Opinion surveys. The special value of these has been demon- 
strated for many years in civil life and needs no emphasis. What is 
perhaps new is this additional understanding that can be given by 
psychiatry. 

(b] Much more experiment is needed and could be undertaken in 
civilian groups along the lines of Moreno's work. 

(r) In civilian life, more is known about delinquency, and more 
has been done, but clearly not nearly enough. The effect of dealing 
more adequately with the psychopathic and delinquent group extends' 
far beyond the individual problems. 

(d) This will be a postwar problem in civilian life, and much 
more study of similar groups is needed if racial and community prob- 
lems are to be handled in the best possible way. Many studies have 
been produced already, and far more are needed. 

9. There is almost unlimited scope for similar activities in industrial 
groups and the large communities. In every community, there should 
be something similar to the morale committee of wartime, which is 
particularly concerned with the collection and collation of data from 
various sources upon which action may be advised. 

10. There is a danger of loose usage of this word "rehabilitation," 
and while results are obtained, we know very little about how they 
come about or how to speed them up or how to deal with our failures. 
A large part of rehabilitation is psychological and much more careful 
study needs to be given to the underlying principles behind the vari- 
ous approaches to differing types of cases. 

11. Planning. The successes achieved in the work carried out in the 
armies is sufficient to encourage us in the idea that social and political 
planning of the future can be very largely helped by psychiatric 
thought and work. The resettlement of the world and the constant 
flow of social problems will provide us with unlimited opportunities 
for attempting wiser direction, and this must be based upon better un- 



I 5 4 THE SHAPING OF PSYCHIATRY BY WAR 

derstanding of the fundamental nature of the problems. There should 
be groups and teams at work all over the world collating their find- 
ings and working to the common end of solving the social, economic 
and spiritual problems of communities and nations. Many types of 
knowledge and experience will be utilized in such groups, but war- 
time experience has made it quite clear that the psychiatric contribu- 
tion is at least as important as any that can be made, provided we 
have the right kind of psychiatrists and sufficient patience to do much 
backroom work. 



INDEX 



Abreact, 80; abrcaction, 116 

Absence without leave, 92; and intelli- 
gence, 43 

Absenteeism, 85, 89, 153 

Adam, General Sir Ronald, n 

Adjutant general, 58, 65, 67 

Africa, 1 1 ; psychiatry in, 50 

Agricultural companies, see Labour com- 
panies 

Allied armies, 83, 108 

Allies, 30, 32 

Amenorrhoea, 95 

American Journal of Psychiatry, 150 

Amnesia, 116 

Anthropology, see Psychiatry 

Anxiety, 66, 95, 108, in, 112 

Army Act, 90 

Army Bureau of Current Affairs (ABC A), 
9B, M5 

Army Selection Training Unit, 79 

Auxiliary Territorial Service, 41, 94-5 

Baptism by fire, 81 

Barbiturates, 115 

Battle of Britain, 82 

Battle inoculation, 81, 82, 144 

Battle neurosis, see Neurosis 

Beveridge, Sir William, 117, 120 

Bion's "leaderlcss group," 69 

Blind, 10 1, 147 

Board of Control, 29 

Borstal institutions, 123 

Bowlby, 75 

Brantford experiment, 57 

Brave New World by Aldous Huxley, 45 

Britain, 10, 44, 88, 102, 117, 122; psychia- 
try in, 14, 20, 25, 29, 30, 32, 33, 35, 
48, 56, 107, 114, 120, 123, 125-6, 127, 
136; psychology in, 34, 74; selection 
in, 36, 42, 61, 76 

British army, n, 14, 121, 135, 143; organ- 
ization of, 32, 42, 49, 54, 57, 79, 88, 
90, 91; selection in, 59, 63, 143; in 
world, 50, 106 

British Expeditionary Force, 56 

British Medical Journal, 22 

Burlingamc, Charles, 109 

Canada, illiterates in, 78; psychiatry in, 



14, 98; psychologists in, 35; selection 

in, 6 1 

Canadian army, 47, 57 

Cape of Good Hope, 56 

"Chest expander," 65 

Child guidance, see Guidance 

Child psychiatry, see Psychiatry, child 

Children's Department, 31 

Cinderella motif, 25 

Civil defence, 53, 76 

Civilian recruiting boards, 36 

Commonwealth Fund, 32 

Correspondence de Napoleon, see Na- 
poleon's letters 

Court-martial, 43, 89, 90-2 

Crime, 45, 80, 89, 90, 145 

Criminal Justice Bill, 122 

Cripple, 100 

Cryptofascist, 93 

Culpm, Millais, 32 

Defective, see Dullard 

Delinquency, 31, 85, 86, 90, 94, 135, 

M6> i53 

Depression, 102; reactive, 48, 80 
Dermatology, 100, 128 
Desertion, 113, 145 
Detention barracks, 91, 101 
Directorate for the Selection of Personnel, 

42, 58, 59 

Discipline, 15, 85, 88-93 
Disenchantment by Montague, 18 
Doctor, 35, 97, in, 112; part in war, 

17-19, 23; trial by, 67, 90; see also 

Education 

Domestic service, 149 
Dullard, 42-5, 56, 112, 133, 142 
Dyspepsia, 100 

Edinburgh, 29 

Education, 96-8; in civil life, in, 151-2; 
medical, 25, 29, 125-6; psychiatric, in 
army, 144; in psychiatry, 125-9 

Education Corps, 145 

English Emergency Medical Service 
(EMS), 38, 46, no 

Erewhon by Samuel Butler, 31 

Europe, 129 

Exhaustion centres, 114, 115 



i 5 6 



INDEX 



Fear, in, 112 

Fifth Column Worf^ for Amateurs, 84-5 

Films, 49, 80, 81, 82, 87-8, 117, M5> M<5 

France, 1 1, 82 

Freud, Sigmund, 28, 67 

German army, 65, 83, 105; officer selec- 
tion in, 67 

Germans, 17, 53, 81, 82 

Germany, 82, 101, 103, 128, 137, 138; 
psychological department of, 34 

Gideon, 33 

Gillespie, R. D., 114 

Guidance, child, 32-3, 39, 123-4; voca- 
tional, 54, 149 

Hallcy Stewart research grant, 65 

Hanson, 114, 116 

Hargreavcs, Lieutenant Colonel G. R., 42, 

57 

Harvard Thematic Apperception test, 72 
Hatred, 80, 83 
Hcaly, William, 31 
Hegel, Georg W. F., 29 
Hood, General Sir Alexander, n 
Hypnosis, 38, 116 
Hysteria, 55 

Illiterates, 78-9, 144 

Impotence, 94 

India, u, 56; psychiatry in, 50 

Industrial Health Research Board, 32 

Interview, 60, 144; psychiatric, 65, 67, 

72-5 
Italy, n, 101, 114 

Japan, 137; Japanese forces, 105 
Job analysis, 142, 148 
Journal of Abnormal and Social Psychol- 
ogy, 127 

Killing, 15, 17 

Labour companies, 30, 149 
Labour Ministry, 148 
Lady Chichcstcr Hospital, 29 
Lawyer, sec Psychiatrist 
"Lcadcrless group," see Bion's 
Leadership, 63, 70, 84 
Lice, and intelligence, 41 
Limbless, 100, 101, 147 
London, 34, 59, 81, in 

McLaughlin, 81 

"Magic eye technique," 64 



Malingering, 43; malingerer hunter, 18 

Man management, 49, 141, 144 

Manpower, 53-62; dullard and, 16, 41, 
42-3, 91; saving of, 49, 114; wasting 
of, i oo 

Maudsley Hospital, 29 

Medical officers, 17, 21; functions of, 17, 
19, 151; industrial, 24; instruction of, 
38, 96, 97, 114, 144 

Medical services, n, 18, 26, 36, 56, 58; 
recommendations for comprehensive, 
120 ff.; social, 19 

Medicine, 28; psychological, 126; psycho- 
somatic, 25, 96; selection in, 119, 128, 
141-2, 149; social, u, 33-7, 45, 51, 62, 
117, 138; see also Doctor, Psychiatry 

Memorial Fund, 9 

Mcnmngcr, Colonel, 84 

Mental health, see Planning 

Mental hygiene, 84 

Mental Hygiene Congress, 30 

Mental Treatment Act, 120 

Middle East, 56, 106 

Mill Hill Neurosis Centre, 116 

Miller, Emanucl, 101 

Ministry of Labour, 48 

Ministry of Pensions, 29 

Morale, 82-8, 89, 141, 146, 153; elements 
in good, 38, 39, 41, 57, 60, 61, 75, 79, 
94, 97> 98, 116, 147; training of, 144-5; 
and war, 17, 49, 81 

Moreno's work, 153 

Munson, 83 

Murray, H., see Harvard Thematic Ap- 
perception test 

Napoleon's letters, 82 

Narcosis, sec Therapy 

Narco-analysis, $8 

National Health Service, 123 

National Institute of Industrial Psychol- 
ogy, 34 

National Service Recruiting Boards, 48 

Nazi, 85, 138 

Nepotism, 50, 75 

Neurology, 127-8 

Ncuropsychiatry, 127 

Neurosis, 1 8, 25, 29, 31, 39, 66, 126, 
130; battle, 19, 28, 37, 49, 61, 106, 
108, 111-16, 144; centres, 40, 46, 108; 
mass, 30, 145; occupational, 149; 
traumatic, 55; treatment of, 20, 107-9, 
122; see also Exhaustion centres 

Ney, Marshal, 112 

Nobel prize, 141 



INDEX 



157 



Noncommissioned officers (NCO's), 44, 

60, 64, 85, 89, no, 113, 115 
Normandy, 96, 114, 115 
North Africa, 114 
Nurses, see Training 

Officer Candidate Training Unit (OCTU), 

64 
Officer Selection Boards, see War Office 

Selection Boards 

Opinion surveys, 50, 86, 145, 153 
Orthopaedics, 100, 128 

Parachutists, 143, 145 

Penrosc-Ravcn Progressive Matrices test, 

57 

Pensions, 29, 64; pensioners, 108 

Pentothal, see Therapy 

Personality investigations, 69, 152; point- 
ers, 72-3 

Pioneer Corps, 44 

Planning, for mental health, 119-25; see 
also Psychiatry, tasks of 

Prisoners of war, 101-5, 146 

Psychiatric examination, 40, 42, 48, 63, 
92 

Psychiatric team, 21, 32, 123 

Psychiatrist, 73-4, 76, 80, 105; area, 22, 
24, 46, 47, 98-9, 133, 141; in the 
army, 19-23; corps, 99; divisional, 96, 
99, 133; Dutch, 136; and lawyer, 90-1; 
and psychologist, 34, 35-7, 71, 97, 99, 
142, 143; qualifications for, 21-2; 
special training of, 23-4; see also Psy- 
chiatry 

Psychiatry, 23, 25-8, 92-3, 105, 107, 133, 
138; and anthropology, 127; area, 98-9, 
141; child, 21, 31-2, 123-4, 126; de- 
scriptive, 30; future of, 117-18, 153; 
industrial, 135; and medicine, 100, 118, 
125, 130; and neurology, 128; priorities 
in, 45-51; research in, 129-30; social, 
n, 136; special enquiries in, 99-101; 
tasks of, in army, in civil life, 140-54; 
see also Education, Guidance, names of 
countries 

Psychoanalysis, 20, 30, 31, 67, 134; back- 
ground of, 21, 146; orthodox group, 
29; personal analysis, 126; understand- 
ing, 137; see also Psychology 

Psychological warfare, 34, 105-6, 143, 147 

Psychologist, 34, 80, 109, 134; industrial, 
32, 141; in social medicine, 33-7; sec 
also Psychiatrist 

Psychology, 33, 35, 126; analytic, 105; 



dynamic, 21; industrial, 33, 34, 135 

150; medical, 22; see also names oi 

countries 

Psychoncuroses, see Neurosis 
Psychopathology, 106, 130 
Psychopathy, 23, 64, 90 
Psychoses, 21, 46, 48, 121, 126, 138 

treatment of, in army, 37, 106-7 
Psychosomatic medicine, see Medicine 
"Psychosurgery," 116 
Psychotherapy, see Therapy 
PULHELMS system, 47 

Radio, 50, 87-8, 146; location, 53, 94-5 
Recidivism, 43 

Red army medical service, 56 
Rehabilitation, 101, 114, 146-7, 149, 153 
Report by the British War Office Com 
mittee of Enquiry into Shell Shocf{, 29 

52-3 

Research and Training Centre, 71 
Rodger, 65 
Rorschach tests, 72 

Royal Air Force (RAF), 16, 58, 61, 114 
Royal Army, 61; sec also British army 
Royal Army Medical Corps Depot, 57 
Royal Navy, 16, 58, 61, 63 
Rudolf, 10 1 
Russia, 83 

Salmon, Doctor Thomas W., 9, 20, 119 

Sandiford, Brigadier Hugh, n 

Sapir, E., 127 

Sargant, 38 

Scabies, and intelligence, 42 

Schools, 58, 63, 64, 77, 132, 148 

Sedation, see Therapy 

Selection, 33, 53, 100, 105, 128, 147, 149 
150; centres (misfit), 46-7; of officers 
62-77; procedures, n, 56-62, 141-4 
tests, 50; vocational, 54; sec also Medi 
cine, names of countries and armies 

Self-Description test, 72 

Sergeant, educational, 78, no; testers 
60, 66, 73 

Service labour corps, 133 

"Shell shock," 20, 28, 55 

Slater, 38 

Smith, May, 32 

Social work, 36, 50, 122 

Social worker, 32, 123, 150 

Sociologists, 36, 37, 51, 131, I34 J 5 T 

Sociology, 33, 130; sociological techniques 
50, 142, 145-6 

Soviet Republics, 130 



i 5 8 



INDEX 



Stephenson, 97 

Strikes, 89, 153 

Surgeon General's Office, 84 

Sutherland, 71, 72 

Tavistock Clinic, 29, 31 

Testing, 115; group, 58, 62; intelligence, 
33, 41-2, 57; officer, 66, 68-70, 73; 
selection, 46 

Tests, group, 59, 60, 65, 72; intelligence, 
56, 67, 71; laboratory, 65; projection, 
72; sec also Selection, Testing 

The New Lot, 88 

The Way Ahead, 88 

Therapy, 134, 151; group, 37, 109, 133, 
152; insulin, 38, 109; international 
therapeutics, 105; narcosis, 109, 116; 
occupational, 37, 109, 147; pentothal, 
1 1 6; psycho-, 29, 31, 109; sedation, 38, 
109, 115-16 

Training, of nurses, 97; psychiatric con- 
tribution to, 77-82; sec also Psychia- 
trist, Education, Morale 

Transference, negative, 27 

Treatment, see Neurosis, Psychosis, Ther- 
apy 

Trist, 71 

Tunisia, 114; Tunisian campaign, 96 



Ulcer, peptic (known in army as sergeant's 

disease), 65 

United Kingdom, 107, 108 
United Nations Relief and Rehabilitation 

Association (UNRRA), 105, 137 
United States, 42, 88; army, 20, 54, 84, 

96, 114; psychiatry in, 9, 14, 30, 32; 

psychology in, 33, 44, 56; selection in, 

61 
United States Army Medical History, 9 

Venereal disease, 18, 45, 101, 145 

War (1914-18), 9, 28, 52, 98, 113; aims, 
83; matures psychiatry, 10 

War Office, posting department, 40 

War Oflicc Selection Boards, 22, 32, 67, 
76; experimental, 66 

Washington (D.C.), 60, 84 

Wchrmacht, 82, 138 

Western Electric, experiments, 33; Haw- 
thorne factory, 60 

Wilson, Lieutenant Colonel, 85, 101 

Wittkowcr, 44, 65, 100 

Women's services in the army, 93-6; 
officers in, 76; see also Auxiliary Ter- 
ritorial Service 

Word Association test, 72 

Workers' Educational Association, 97 



THE THOMAS WILLIAM SALMON 
MEMORIAL LECTURES 



The Salmon Lectures of the New York Academy of Medicine were estab- 
lished in 1931, as a memorial to Thomas William Salmon, M.D., and for the 
advancement of the objects to which his professional career had been wholly 
devoted. 

Dr. Salmon died in 1927, at the age of 51, after a career of extraordinary 
service in psychiatric practice and education, and in the development of a 
world-wide movement for the better treatment and prevention of mental 
disorders, and for the promotion of mental health. 

Following his death, a group of his many friends organized a committee 
for the purpose of establishing one or more memorials that might serve to 
preserve and pass on to future generations some of the spirit and purpose of 
his supremely noble and useful life. Five hundred and ninety-six subscriptions 
were received, three hundred and nineteen from physicians. 

Of the amount thus obtained, $100,000 was, on January ro, 1931, given to 
the New York Academy of Medicine, as a fund to provide an income for the 
support of an annual series of lectures and for other projects for the advance- 
ment of psychiatry and mental hygiene. For the purpose of giving lasting 
quality to the lectures as a memorial to Dr. Salmon, and of extending their 
usefulness, it was stipulated that each series should be published in a bound 
volume of which this volume is one. 



Lectures Previously Published in This Series 

Destiny and Disease in Mental Disorders By C. Macfie Campbell 

Twentieth Century Psychiatry By William A. White 

Reading, Writing and Speech Problems in Children By Samuel Torrey Orton 
Personality in Formation and Action By William Healy 

Psychopathic States By D. K. Henderson 

Beyond the Clinical Frontiers By Edward A. Strecl(er 

A Short History of Psychiatric Achievement By Nolan D. C. Lewis 

Psychological Effects of War on Citizen and Soldier By Robert D. Gillespie 

Psychiatry in War By Emilio Mira 
Freud's Contribution to Psychiatry By A. A. Brill